The findings of the combined Change of Ownership and Facility Enhanced Oversight and Supervision surveys, conducted 05/13/24 through 05/16/24 are documented in this report. The surveys were 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
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 areas:
OAR 411-054-0025 (4): Reasonable Precautions;
OAR 411-054-0027 (1): Resident Rights and Protections; and
OAR 411-054-0040 (1-2): Change of Condition and Monitoring.
The facility put an Immediate Plan of Correction in place during the survey.
The findings of the first re-visit to the re-licensure survey of 05/16/24, conducted 09/23/24 through 09/25/24, 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.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Tag numbers beginning with the letter H refer to the Home & Community-Based Services rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second revisit to the re-licensure survey of 05/16/24, conducted on 03/19/25, 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 licensee failed to ensure adequate administrative oversight of facility operations and supervision which posed a risk to the safety of residents. Findings include, but are not limited to:
During the combined Change of Ownership and Facility Enhanced Oversight and Supervision surveys, conducted 05/13/24 through 05/16/24, 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. Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:
OAR 411-054-0025 (4): Reasonable Precautions;
OAR 411-054-0027 (1): Resident Rights and Protections; and
OAR 411-054-0040 (1-2): Change of Condition and Monitoring.
The facility put an Immediate Plan of Correction in place during the survey.
2. Refer to deficiencies in the report.
1. Facility acknowleges the statement of deficiencies and the following plan of correction outlines the actions put in place to correct the situations where the facility failed to comply with the Department's rules.
2. Each tag identifies the system error and the corrective action that the facility will take.
3. The areas needing corrected will be evaluated as stated with each citations.
4. Administrator and Regional Director will be responsible to monitor that corrective action is being taken, along with the mandated nurse consultant through ElderWise Inc. and the FEOS program through the assigned policy analyst.
Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:
A group interview was conducted on 05/14/24 at 10:00 am. Multiple alert and oriented residents provided information on services received in the community. Residents expressed concerns in areas including poor quality of food and no scheduled activities on the weekends. Responses included:
* "...nothing happening on weekends...boring";
* "Dinner is always late, supposed to be served at 5:30, wait for hours sometimes and not served until after 7...";
* "Too much chicken and never get dark meat...";
* "Meats are cooked too long and difficult to eat."; and
* "Servers do not know what is in being served...menu is not clear."
The Food Committee Meeting notes dated between 02/08/24 and 04/11/24 were reviewed. Comments included:
* On 02/08/24 - "Residents would like dark meat, they like wings and drumsticks. Chicken and fish are baked until they are dry. Should redo menu to say exactly what is being served.";
* On 03/14/24 - "Would like dark meat. Would like choice of chicken meat not just chicken breasts. Wait too long for meals, up to an hour sometimes."; and
* On 04/11/24 - "Meals have been late...served between 6:30-7 pm. Would like dark meat, thighs and drums."
In an interview with Staff 7 (Resident Activities Program Director) on 05/14/24, she acknowledged there were no scheduled activities on the weekends.
In an interview with Staff 22 (Dietary Services Director) on 05/14/24, he explained he would talk with residents to try to please them. He acknowledged there was no evidence of resident complaints being responded to.
Documentation of the facility's method of responding to and resolving resident complaints was requested on 05/15/24. Staff 1 (Wellness Director) and Staff 2 (Memory Care Director) reported there was no documented evidence resident complaints had been responded to or resolved.
The need to ensure the facility implemented effective methods of responding to and resolving resident complaints was discussed with Staff 1 (Wellness Director) and Staff 4 (RN) on 05/16/24. They acknowledged the findings.
1.
a. The food committee meeting notes have been reviewed by the Culinary Director and responses have been recorded.
b. The menu will be updated and suggestions/requests from residents will be incorporated as reasonably able each month.
c. Staff education on menu items has been conducted, and will be ongoing as needed from the Culinary Director.
2.
a. Monthly Food service meeting notes will be drafted and responded to by department as noted.
3. This area will be evaluated monthly at CQI meetings, Activity director will bring monthly committee notes and team will review and create responses as needed.
4. Administrator will be responsible to monitor that resident complaints have been responded to during CQI meetings.
Based on observation, interview, and record review, it was determined the facility failed to conduct ongoing quality improvement programs that evaluated services, resident outcomes, and resident satisfaction. Findings included, but are not limited to:
During the survey, conducted 05/13/24 through 05/16/24, quality improvement oversight to ensure adequate resident care, services, and satisfaction was found to be ineffective.
In an 05/14/24 interview with Staff 1 (Wellness Director) and Staff 23 (Regional Wellness Director) it was confirmed the licensee had a quality improvement audit program available to the facility; however, the facility had not yet implemented the program.
The need to ensure the facility conducted an ongoing quality improvement program that evaluated services, resident outcome and satisfaction was discussed with Staff 1 and Staff 23 on 05/16/24. They acknowledged the findings.
Refer to the deficiencies in the report.
1. Immediate CQI meeting will be completed on June 12th. Additional meetings to be held 6/26/24; and again 7/11/24, and monthly on 2nd Wednesday thereafter.
2. Monthly meetings will be held the 2nd Wednesday of each month going forward.
3. Will be evaluated on dates as stated in question 1. Then monthly and as needed for concerns.
4. Administrator will be responsible to conduct monthly meetings.
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (# 1) who had a known history of sexual, physical, and verbal behaviors toward other residents. This placed residents at risk and constituted an immediate threat to the residents' physical and emotional health and safety. Findings include, but are not limited to:
Resident 1 moved from the facility's MCC to the Assisted Living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction. Throughout the survey, Resident 1 was frequently observed sitting near the front desk at the entrance of the facility.
The resident's service plan that was available to staff, dated 12/13/23, incident reports, and observation notes were reviewed, observations of the resident were made, and interviews with staff and residents were conducted. The following was identified:
There was no documented evidence of a completed evaluation for Resident 1's move from the MCC to the AL community.
The service plan revealed the resident had a history of sexual encounters with residents, making sexual remarks to residents and becoming agitated, cursing, yelling and/or threatening harm. Staff were instructed to attempt to re-direct the resident with conversation, TV, or a snack if behaviors were observed.
During an interview with Staff 6 (Medication Room Supervisor RCC) on 05/14/24 at 3:23 pm, Staff 6 stated Resident 1 had "sexual encounters" when s/he lived in the MCC, and when Resident 1 moved into the AL s/he "tried with several residents and they got scared...they spoke to [Resident 1] and [Resident 1] backed off."
Resident 6 moved into the facility in 03/2022 with diagnoses including a history of anxiety, depression, and panic attacks. Resident 6 was dependent on direct-care staff for mobility and was observed being escorted to a meal, at a meal in the dining room, and in his/her room.
On 05/15/24 at 12:51 pm, Staff 24 (CG) stated she was aware Resident 1 had a history of aggressive sexual, physical, and verbal behaviors with residents in the MCC. Resident 6 told Staff 24 that Resident 1 made verbal threats toward him/her that made Resident 6 feel "unsafe" and that a "family [member] or friend" of Resident 6 told Staff 24 that Resident 1 was to have "no contact" with Resident 6.
At 2:41 pm on 05/15/24, Staff 1 (Wellness Director) and Staff 4 (RN) confirmed they were aware of Resident 1's sexual behavior history, including his/her sexual encounters in the MCC. Additionally, Staff 1 was aware of the "verbal altercation" between the residents during the week of 05/06/24. Staff 1 and Staff 4 acknowledged neither had a conversation with Resident 6 about the verbal altercation or completed an investigation ruling out abuse and/or neglect on the reported incident.
On 05/15/24 at 3:47 pm in an interview with Resident 6, s/he made several statements regarding Resident 1's behavior, including a history of Resident 1 making derogatory or sexual comments and behaving in a threatening manner toward Resident 6 by saying "[s/he] is a fire to be put out," Resident 1 told Resident 6 s/he "had been in the MCC and assaulted people, expected charges, but got away with it," and reported these interactions with Resident 1 had left him/her feeling "threatened" and "unsafe." These events were communicated to staff and Resident 6 stated, "no one is coming to ask me how I feel."
Additionally, Resident 6 reported Resident 1 would sit at Resident 6's table, even though Resident 6 had requested repeatedly for Resident 1 not to sit with him/her. Resident 6 stated at lunch service on 05/09/24, Resident 1 called Resident 6 a "B****" and an unsampled resident a "C***." Resident 6 described Resident 6's behavior as "highly agitated" at that time. When Staff 1 and Staff 4 entered the dining room, Staff 1 stated to Resident 1, "you need to behave" and Staff 4 brought Resident 1 a boxed meal, patted him/her on the back, and asked, "Are you ok?" Resident 1 responded, "No! I have no power."
It was determined staff were aware of Resident 1's history of sexual, physical, and verbal aggression toward other residents and the recent verbal altercation between Resident 1 and Resident 6 during the week of 05/06/24.
There was no documented evidence of the incident or what precautions or interventions the facility took to ensure the safety of Resident 6. The facility's failure to ensure the health, safety, and welfare of residents placed Resident 6 and other unsampled residents at risk and constituted an immediate threat to the residents' health, safety, or welfare.
An immediate plan of correction was requested on 05/15/24. The facility provided a plan of correction that was accepted on 05/15/24 at 8:22 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.
The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 4, Staff 6, and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
1. Growth and Wellness Plan (service Plan) has been updated for named resident. Resident also has safety plan in place and is on increased observation.
2. No Move-in or transfer shall occur wihtout full evaluations and assessments completed as though a move is not internal. All required assessments will be in place prior to a transfer.
3. Will be evaluated with each potential transfer.
4. Administrator and LN's will be responsible for managing this expectation.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents had a safe and homelike environment for 1 of 1 sampled resident (# 6) whose record was reviewed. This placed residents at risk and constituted an immediate threat to the residents' physical and emotional health and safety. Findings include, but are not limited to:
Resident 6 moved into the facility in 03/2022 with diagnoses including a history of anxiety, depression, and panic attacks. Resident 6 was dependent on direct-care staff for mobility and was observed being escorted to the dining room as well as in his/her room. Resident 6's service plan, dated 01/24/24, incident reports, and Temporary Service Plans (TSPs) were reviewed.
Resident 1 moved from the facility's MCC to the Assisted Living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
Throughout the survey, Resident 1 was frequently observed sitting near the front desk at the entrance of the facility. Resident 1's service plan that was available to staff, dated 12/13/23, incident reports, TSPs, and observations notes dated 03/10/24 through 05/13/24 were reviewed.
Resident 1's service plan revealed the following:
* "[Resident 1] will occasionally have sexual encounters with [residents of the opposite gender] and will also speak with sexual content to [residents of the opposite gender]";
* "If [Resident 1] is involved in a sexual incident, staff [are] to attempt to redirect. If this does not work staff [are] to complete frequent check[s] to ensure that [s/he] is safe and not in distress"; and
* "[Resident 1] can become agitated, curse, yell and/or threaten harm to others when s/he feels that they are being disrespectful or mean to [him/her]."
On 05/15/24 at 12:51 pm, Staff 24 (CG) stated she was aware Resident 1 had a history of aggressive sexual, physical, and verbal behaviors with residents in the MCC. Resident 6 told Staff 24 that Resident 1 made verbal threats toward him/her that made Resident 6 feel "unsafe" and that a "family [member] or friend" of Resident 6 told Staff 24 that Resident 1 is to have "no contact" with Resident 6.
During an interview with Resident 1 on 05/15/24 at 1:31 pm, s/he confirmed s/he had lived in the facility MCC, had wanted to move to the AL and would "f*** anyone up who got in [his/her] way". Throughout the interview, Resident 1 made multiple comments related to visiting another resident "in the other neighborhood" and a repetitive thought of having "[dug] a ditch [and/or hole]", forced a resident in the [ditch or hole], "forced [him/her] to take it", and "forced [him/her] to like it, until [s/he] did."
On 05/15/24 at 2:41 pm, Staff 1 confirmed she overheard an altercation between Resident 1 and another resident. Staff 1 and Staff 4 (RN) also confirmed they had not investigated the incident or documented it in either resident's record.
On 05/15/24 at 3:47 pm, Resident 6 reported multiple interactions that made him/her feel "threatened" and "unsafe" by Resident 1, which had been going on for approximately a year. Resident 6 stated the following:
* Resident 1 told Resident 6 that s/he "had been in the MCC and assaulted people, expected charges, but got away with it";
* Resident 6 asked Resident 1 not to sit with him/her on multiple occasions and in response Resident 1 would posture and stare at Resident 6;
* Called Resident 6 and other residents sexually explicit names in the dining room;
* Resident 1 would "hang out in the back hall" around Resident 6's room throughout the evening until redirected;
* Resident 1 said "[Resident 6] was a fire to put out"; and
* During lunch service on 05/09/24, Resident 1 called Resident 6 and another resident sexually explicit names. Resident 1 appeared highly agitated. When Staff 1 and Staff 4 entered the dining room, Staff 1 stated to Resident 1 "you need to behave" and Staff 4 brought Resident 1 a boxed meal, patted him/her on the back, and asked "Are you ok?" Resident 1 responded "No! I have no power."
On 05/15/24 at 4:50 pm, the surveyors reported the situation to the local APD department.
The facility failed to ensure Resident 6 and other unsampled residents resided in a safe and homelike environment by failing to address Resident 1's sexual, physical, and verbal behaviors. This placed Resident 6 and other residents at risk and constituted an immediate threat to the residents' health, safety, or welfare. An immediate plan of correction was requested on 05/15/24. The facility provided a plan of correction that was accepted on 05/15/24 at 8:22 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.
The need to ensure residents had a safe and homelike environment was discussed with Staff 1, Staff 4, Staff 6, and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
1. Resident named has been evaluated, growth and wellness plan has been updated to reflect interactions with others, and increased monitoring and safety plan has been initiated.
2. All direct care staff, Culinary, Housekeeping, LN, Admin and RCC will take the Oregon Care Partners course Elder Abuse Prevention, investigation and reporting. Reports will be made as required.
3. Service plan for named resident to be reviewed weekly x4 weeks, then ongoing at regular 90 day intervals per regulations.
Training will be audited weekly, with final audit being 6/28/2024, then will be added to the annual training calendar in the facility.
4. Resident Care Coordinator, LN and Administrator will be responsible to ensure that service plan is monitored for named resident.
Training will be monitored by BOM for initial training and then annually.
Based on interview and record review, it was determined the facility failed to immediately report abuse and suspected abuse to the local Seniors and People with Disabilities (SPD) office, promptly investigate reports of abuse and suspected abuse with all required components documented and take measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (# 1) who was reviewed. Findings include, but are not limited to:
Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
The resident's service plan that was available to staff, dated 12/13/24, "Observation" notes, dated 03/10/24 through 05/13/24, incident reports, and temporary service plans were reviewed, observations of the resident were made, and interviews with staff and residents were conducted.
Resident 1's service plan indicated "[Resident 1] can become agitated, curse, yell and/or threaten harm to others when he feels that they are being disrespectful or mean to him."
On 05/15/24 at 3:47 pm, Resident 6 reported s/he had multiple negative interactions with Resident 1 since s/he moved into the facility, some of which have left him/her feeling threatened. Most recently during lunch service on 05/09/24, Resident 6 reported Resident 1 called Resident 6 a sexually explicit name. In response, an unsampled resident told Resident 1, s/he could be removed from the dining room if s/he spoke like that. Resident 6 stated, Resident 1 appeared highly agitated at that time. When Staff 1 (Wellness Director) and Staff 4 (RN) entered the dining room, Staff 1 stated to Resident 1 "you need to behave" and Staff 4 brought Resident 1 a boxed meal, patted him/her on the back, and asked, "Are you ok?" Resident 1 responded, "No! I have no power."
On 05/15/24 at 4:16 pm in an interview with Staff 29 (CG), she confirmed Resident 1 was involved in a verbal altercation with Resident 6 during the week of 05/06/24. Staff 29 stated she reported the incident to Staff 1 during the week of 05/06/24 and again on 05/15/24.
On 05/15/24 at 2:41 pm, Staff 1 confirmed she was aware of the recent verbal altercation between Resident 1 and Resident 6 but did not talk to Resident 6 or complete an investigation.
The facility failed to report abuse or suspected abuse to the local SPD office, promptly investigate reports of abuse and suspected abuse, and take necessary measures to prevent the reoccurrence of abuse. The facility was informed the survey team had reported this incident to the local SPD office on 05/15/24 at 4:52 pm.
The need to ensure abuse, and suspected abuse was reported to the local SPD office, reports of abuse and suspected abuse were promptly and properly investigated, necessary measures were taken to prevent the reoccurrence of abuse was discussed with Staff 1, Staff 4 and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
1. Immediate action taken by the community to update service plan, create safety plan around named resident and report incident to local SPD office.
2. Facility will educate staff regarding reporting requirements. All staff will take class through Oregon Care partners- Elder Abuse Prevention, investigation and reporting. Facility will initiate daily clinical meetings and checks for incident reporting.
3. Facility will audit training weekly, with one comprehensive audit on June 28th, all staff will complete training by 7/14/24. IR's will be reviewed daily and reported as needed to the local SPD office.
4. Administrator and LN's responsible to review reporting. BOM responsible to track training.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations were completed and were updated or changed as appropriate within the first 30-days after move-in for 1 of 1 sampled resident (# 1) whose move-in evaluation was requested for review. Findings include, but are not limited to:
Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
Resident 1's new move-in evaluation was requested from the facility multiple times between 05/13/24 and 05/16/24.
On 05/16/24 at 10:07 am, Staff 1 (Wellness Director), Staff 4 (RN), Staff 6 (Medication Room Supervisor/RCC) and Staff 23 (Regional Wellness Director) confirmed they could not provide documented evidence the facility performed a move-in evaluation or an update within 30-day of move-in for Resident 1.
The need to ensure move-in evaluations were completed and were updated or changed as appropriate within the first 30-days after move-in was discussed with, Staff 1, Staff 4, Staff 6, and Staff 23 on 05/16/24. They acknowledged the findings, and no additional documentation was provided.
1. Evaluations of residents named have been updated with all aspects of evaluation requirements.
2. Move-In evaluations will be reviewed by Admin and LN's, 30-day evaluation meeting will be scheduled on the same day of move-in.
3. Every month at CQI meeting will review previous month move-ins to ensure meetings have been scheduled, and move-in evaluations are completed will all elements required.
4. Administrator, LN's and Resident care Coordinator.
2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including unspecified osteoarthritis and overactive bladder.
The resident's 04/05/24 service plan was reviewed, observations were made of the resident and interviews with the resident and staff occurred throughout the survey.
a. The service plan was not reflective of the resident's needs and preferences and did not give clear instruction to the staff in the following areas:
* Mobility;
* Incontinent care, including number of required staff, history of refusals and location;
* Meal preparations;
* Behavior medication; and
* Sleeping preferences.
b. On 05/13/24, Resident 3's 04/05/24 service plan was noted as not accessible to care staff.
The need to ensure Resident 3's service plan was reflective, gave clear instruction to staff and was made available to staff was discussed with Staff 1 (Wellness Director), Staff 4 (RN) and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
3. Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
The resident's service plan that was available to staff, dated 12/13/24, and a temporary service plan, dated 03/21/24, were reviewed, observations of the resident were made, and interviews with staff were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas:
a. The service plan was not reflective of the resident's needs and preferences and did not give clear instruction to the staff in the following areas:
* Current medication administration needs and history of forgetting to take medications;
* Bathing, including history of refusals around bathing and staff management of the resident's refusals;
* Fall interventions;
* Grooming/Personal Hygiene, including behaviors and staff instruction to manage behaviors;
* Dressing preferences, including time of day, clothing, and instruction to staff regarding behaviors;
* Meals, including behaviors during meals;
* Nighttime care needs;
* Shopping and finances, including not having a designated person to manage finances; and
* Activities, including current interests and hobbies.
b. The service plan was not implemented in the following areas:
* Wandering behaviors inside the community; and
* Monthly vitals.
c. Throughout the survey, Resident 1's current service plan, dated 03/25/24, was not accessible to care staff.
The need to ensure service plans were reflective, provided clear direction to staff, were implemented, and available to staff was discussed with Staff 1 (Wellness Director), Staff 4 (RN) and Staff 23 (Regional Wellness Director) on 05/16/24. 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 status, provided clear instructions to staff, and were updated at least quarterly for 3 of 4 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in September 2023 with diagnoses including obesity.
Observations, interviews with the resident and staff during the survey, and review of the current service plan, dated 01/22/24, revealed the service plan was not reflective of the resident's current status and/or failed to provide clear instructions to staff in the following areas:
* Toileting;
* Transfers;
* Skin; and
* Refusal of care.
Additionally, Resident 2's current service plan, dated 01/22/24, had not been updated quarterly.
On 05/15/24, the need to ensure service plans were updated following completion of quarterly evaluations, were reflective of the resident's current status, and provided clear direction to staff was discussed with Staff 1 (Wellness Director), Staff 4 (RN), and Staff 23 (Regional Wellness Director). They acknowledged the findings.
1. Growth and Wellness plans (service plans) of named resident have been updated with current condition. Service plans of all residents will be audited on a tiered system over next 90 days to ensure that service plans are reflective of most current condition.
2. Going forward the facility will utilize the software system implemented in March of 2024 to enter and manage growth and wellness plans.
3. This will be reviewed monthly x 3 months to ensure growth and wellness plans are up to date.
4. Administrator, LN's and resident care coordinators will monitor and manage scheduling of service plans.
2. Resident 3 was admitted to the facility in 01/2023 with diagnoses including overactive bladder and chronic pain.
Interviews and reviews of the resident's 02/21/24 through 05/13/24 progress notes, 04/01/24 through 05/13/24 MAR's, 04/05/24 service plan and temporary service plans revealed the resident experienced the following short term changes of condition:
* 02/24/21 - Wound to left heel;
* 03/15/24 - Excoriation to bilateral buttocks;
* 04/25/24 - Incontinent care refusals; and
* 05/03/24 - Abrasion to back.
There was no documented evidence the facility determined and documented resident specific actions or interventions needed related to the fall, skin concerns or missed medications, communicated interventions to staff on each shift, or monitored the conditions with the progress noted at least weekly through resolution.
The need to ensure residents who experienced short term changes of condition were evaluated to determine if actions or interventions were needed, actions or interventions were communicated to staff on each shift and documented at least weekly with progress noted until the condition resolved was discussed with Staff 1 (Wellness Director) and Staff 4 (RN) on 05/16/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific interventions were determined for short-term changes of condition, documented and communicated to staff on each shift, the determined interventions or conditions were monitored per the residents' evaluated needs and service plan with weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Resident 1 demonstrated verbal and sexual behaviors that were not monitored. This placed residents at risk and constituted an immediate threat to the residents' physical and emotional health and safety. Findings include, but are not limited to:
1. Resident 1 moved from the facility's MCC to the Assisted Living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction. Throughout the survey, Resident 1 was frequently observed sitting near the front desk at the entrance of the facility.
Resident 1's service plan stated, "[Resident 1] will occasionally have sexual encounters with [opposite gendered residents] and will also speak with sexual content to [opposite gendered residents]," and "[Resident 1] can become agitated, curse, yell and/or threaten harm to others."
On 05/14/24 at 3:23 pm, Staff 6 (Medication Room Supervisor RCC) stated Resident 1 had "sexual encounters" when s/he lived in the MCC and when Resident 1 moved into the assisted living side of the building s/he "tried with several residents and they got scared...they spoke to [Resident 1] and [Resident 1] backed off."
Resident 6 moved into the facility in 03/2022 with diagnoses including a history of anxiety, depression, and panic attacks. Resident 6 was dependent on direct-care staff for mobility and was observed at meals in the dining room as well as in his/her room.
On 05/15/24 at 3:47 pm, Resident 6 reported multiple interactions that made him/her feel "threatened" and "unsafe" by Resident 1 for about a year. Resident stated the following:
* Resident 1 told Resident 6 that s/he "had been in the MCC and assaulted people, expected charges, but got away with it";
* Resident 6 asked Resident 1 not to sit with him/her on multiple occasions and in response Resident 1 would posture and stare at Resident 6;
* Called Resident 6 and other residents sexually explicit names in the dining room;
* Resident 1 would loiter around Resident 6's room throughout the evening until redirected;
* Resident 1 said "[Resident 6] was a fire to put out"; and
* During lunch service on 05/09/24, Resident 1 called Resident 6 and another resident sexually explicit names. Resident 1 appeared highly agitated. When Staff 1 (Wellness Director) and Staff 4 (RN) entered the dining room, Staff 1 stated to Resident 1 "you need to behave" and Staff 4 brought Resident 1 a boxed meal, patted him/her on the back, and asked "Are you ok?" Resident 1 responded "No! I have no power."
At 2:41 pm on 05/15/24, Staff 1 (Wellness Director) and Staff 4 (RN) confirmed they were aware of Resident 1's sexual behavior history and that s/he had sexual encounters in the MCC. Additionally, they were aware of the verbal argument between Resident 1 and another resident the week of 05/06/24. Facility staff were unable to provide documented evidence that Resident 1's behaviors were monitored consistent with his/her needs.
It was determined the facility was aware of Resident 1's history of aggressive sexual, physical, and verbal behaviors towards residents. There was no documented evidence to demonstrate Resident 1 was monitored consistent with his/her evaluated needs and service plan following Resident 6's reporting of past and more recent altercations with Resident 1.
The facilities failure to monitor Resident 1's potentially aggressive behavior, evaluate behavioral interventions, and/or develop new interventions when Resident 1's behaviors continued placed Resident 6 and other residents at risk of physical and emotional harm and constituted an immediate threat to residents' health, safety, and welfare.
An immediate plan of correction was requested on 05/15/24. The facility provided a plan of correction that was accepted on 05/15/24 at 8:22 pm, prior to survey exit. The immediate risk was addressed; however, the facility will need to evaluate the overall system failure associated with the licensing violation.
The need to ensure the facility monitored residents consistent with his/her evaluated needs and service plan was discussed with Staff 1, Staff 4, Staff 6, and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings, and no additional documentation was provided.
3. Resident 2 was admitted to the facility in September 2023 with diagnoses including obesity.
Resident 2's record was reviewed for changes of condition and on 03/22/24 identified the resident experienced a wound re-opened on his/her abdomen.
During an interview with Staff 1 (Health and Wellness Director/Administrator) and Staff 4 (RN) on 05/15/24, it was reported the resident's wound had resolved on 05/03/24.
There was no documented evidence the facility had monitored the resident's wound weekly until resolution.
On 05/15/24, the need to ensure residents who experienced a change of condition were monitored at least weekly until resolution was discussed with Staff 1, Staff 4, and Staff 23 (RN/Regional Director of Wellness Director). They acknowledged the findings.
1.
a. Service plan for resident #1 updated immediately and safety plan implemented. Change of condition service plan initiated.
b. Resident 6's service plan updated; facility implemented safety plan.
c. Resident #3's service plan was updated, notes by RN in place, home health initiated, higher level of care obtained for accepting resident. Resident moved out as of 5/31/24.
2. Daily clinical meetings in place, RN has enrolled in the role of the RN class. Change of condition class through Oregon Care Partners assigned.
3. Change of condition monitoring will be reviewed no less than weekly for 4 weeks, then monthly to ensure all changes have been captured.
4. LN and Administrator will be responsible to implement significant changes of resident services.
Based on and interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as prescribed in OAR 411-054-0050 Infection Prevention and Control. Findings include, but are not limited to:
In an interview on 05/15/24 Staff 4 (RN) was identified as the facility's Infection Control Specialist.
The facility lacked documented evidence Staff 4 had completed the required specialized, Department-approved training in infection prevention and control protocols for a Residential Care Facility infection control specialist.
The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 (Wellness Director) Staff 4 and Staff 23 (Regional Wellness Director) on 05/16/23. They acknowledged the findings.
1. Infection control specialist was identified.
2. LPN and RN have both taken the infection control specialist training.
3. This community will required the RN to be the designated infection control specialist going forward and will need to be reviewed with personel changes in the facility.
4. Administrator will be responsible to assign the rold of infection control specialist.
Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication administration systems. Findings include, but are not limited to:
1. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:
C 302: Systems: Systems: Tracking Control Substances;
C 303: Systems: Treatment Orders;
C 310: Systems: Medication Administration;
C 330: Systems: Psychotropic Medication; and
C 372: Training within 30 days: Direct Care Staff.
The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Wellness Director), Staff 4 (RN) and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
2. Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
The resident's physician orders, the Controlled Substance Disposition logs, prescription bottles, and the MAR, dated 04/01/24 through 05/14/24, were reviewed.
Resident 1 had a physician order for hydrocodone 5-325 mg - take 1/2 tablet by mouth every six hours as needed (for pain). The resident's prescription bottle of hydrocodone, which was observed in the facility's locked medication cart, had a "discard after" date of 04/04/24.
The Controlled Drug Record and the MAR indicated the resident received two doses of the expired hydrocodone, one on 04/13/24 and the other on 04/15/24.
The administration of medication following the pharmacy issued discard by date was addressed with Staff 1 (Wellness Director), Staff 23 (Regional Wellness Director), and Staff 6 (Med Room Supervisor/RCC) on 05/14/24 at 5:17 pm.
The need to ensure the facility had a safe medication administration system in place was reviewed with Staff 1, Staff 4 (RN), Staff 6, and Staff 23 on 05/16/24. They acknowledged the findings.
1.
a. Full autid will be completed
b. Inventory control has been rolled out utilizing the medication management software system.
c. Software training will be implemented for all staff regarding the inventory management.
d. Med Cart Audit to be completed by 6/21 to ensure expired medications destroyed.
2. Electronic inventory control system rolled out on 5/27/24 that will assist to manage and monitor the documentation. MT training and education to be completed by 6/21 to ensure that records are accurate.
3. LN's to audit weekly x4 weeks and then monthly at CQI meetings.
4. LN's and Resident Care Coordinators are responsible to monitor and manage controlled substance records and auditing.
2. Resident 4 was admitted to the facility in 09/2022 with diagnoses including anxiety disorder.
The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 04/01/24 through 05/12/24, were reviewed.
Resident 4 had a physician order for alprazolam 0.25 mg - take one tablet by mouth daily at bedtime as needed for anxiety.
Between 04/17/24 through 05/12/24, the Controlled Drug Record indicated staff signed as having removed a tablet of alprazolam from locked storage 26 times. However, during the same time period, the MAR indicated the resident was administered the medication 15 times. This was a discrepancy of 11 pills.
Discrepancies between the MAR and the narcotic log were reviewed on 05/14/24 at 5:17 pm with Staff 1 (Wellness Director), Staff 23 (Regional Wellness Director), and Staff 6 (Medication Room Supervisor/RCC).
The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1, Staff 4 (RN), Staff 6, and Staff 23 on 05/16/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 4 and 5) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in March 2023 with a diagnosis of osteoarthritis. Resident 5 had signed physician's orders for PRN Acetaminophen-Codeine 300-30 mg every 4 hours as needed for pain.
Review of controlled substance disposition logs and Resident 5's 04/01/2024 through 05/13/2024 MAR identified 14 occasions where the Acetaminophen-Codeine was documented as being removed from storage in the disposition log but was not documented as administered on the MAR.
During an interview on 05/13/24, Staff 6 (Medication Room Supervisor/RCC) reported ensuring the controlled disposition log and the MAR were reflective of one another, was an area the facility was providing ongoing training to staff in.
On 05/15/24, the need to ensure controlled disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Wellness Director), Staff 4 (RN), and Staff 23 (Regional Wellness Director). They acknowledged the findings.
1. Pharmacy consultant contacted to conduct staff training on software system to ensure that inventory control is completed correctly.
2. Electronic inventory system implemented to manage and monitor documentation.
3. This area will be evaluated weekly x4 weeks, bi-weekly x4 weeks and then monthly with inventory spot checks. This will also be evaluated as needed with any inventory discrepancies reported.
4. The LN's and resident care coordinators will be responsible to monitor inventory control.
2. Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD) and cognitive dysfunction.
The resident's 01/30/24 Veterans' Affairs (VA) physician orders, 03/19/24 physician orders, and faxed correspondence with the physician from 03/19/24 through 04/19/24, were reviewed and the following was identified:
Resident 1 had physician orders from the VA dated 01/30/24 to receive the following medications:
* Lisinopril 20mg - one tab BID (for blood pressure);
* Venlafaxine 75 mg - one tab daily (for mood); and
* Tamsulosin 0.4 mg - one cap daily (for urinary retention).
These medications were discontinued on the same set of VA physician orders.
Resident 1's current physician orders, dated 03/19/24, had a handwritten note from the resident's physician stating the following medications were "missing from this list - compared to VA list":
* Lisinopril 20mg one tab BID (for blood pressure);
* Venlafaxine 75 mg one tab daily (for mood); and
* Tamsulosin 0.4 mg one cap daily (for urinary retention).
Discontinuation orders for the resident's lisinopril, venlafaxine, and tamsulosin were requested from Staff 1 (Wellness Director) on 05/14/24 at 11:57 am. No discontinuation orders were provided by the facility.
In an interview with Staff 6 (Medication Room Supervisor RCC) on 05/14/24 at 3:23 pm, she confirmed the medications had been discontinued in error on 03/10/24, and Resident 1 had not received the medications since that date. On 05/16/24 at 10:07 am, Staff 6 informed the survey team the facility received refills of the resident's erroneously discontinued medications that morning.
The need to ensure medication orders were carried out as prescribed was discussed with Staff 1, Staff 4 (RN), Staff 6, and Staff 23 (Regional Wellness Services Director) on 05/16/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure written and signed physician orders were documented in resident records for all medications and treatments administered and that physician orders were being carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 2's 04/01/24 through 05/13/23 MAR and signed physician orders were reviewed during the survey. The following was identified:
a. Resident 2 had an Insulin Aspart 100 unit/ml pen order to be administered based on their blood glucose level (CBG) at 08:00 am, 12:00 pm, and 05:00 pm daily. Sliding scale parameters were listed on the MAR as follows:
* Two units for CBG 101-150;
* Four units for CBG 151-200;
* Six units for CBG 201-250;
* Eight units for CBG 251-300;
* Ten units for CBG 301-350;
* Twelve units for CBG 351-400; and
* Fourteen units for CBG above 400.
Resident 2's MAR on 04/07/24, 04/23/24, and 05/10/24 indicated s/he received the incorrect dose of insulin based on the sliding scale physician orders. The MAR on 05/09/24, noted the resident had not received his/her 12:00 pm dose of insulin.
b. A signed physician order to administer Levothyroxine 75 mcg once a day, had not been administered on four occasions.
On 05/15/24, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Wellness Director), Staff 4 (RN), and Staff 23 (Regional Director). They acknowledged the findings.
1.
a. Med-Tech's involved in named citation were re-delegated for insulin and trained on sliding scale and expectations to follow physician orders.
b. Med-Tech's involved in levothyroxine omission were addressed and physician notified. Requirements to carry out physician's orders reviewed.
c. Orders clarified for resident #1 and medications implemented ASAP after receiving clarification.
2. Going forward insulin delgation will be continued, staff education to be completed with all med-techs regarding accurate documentation of medication records, and regulation to carry out physician's orders as prescribed.
3.
a. Weekly insulin audits to be conducted x4 weeks then monthly spot checks for accurate administration.
b. Weekly MAR hole reports to be pulled and followed up on x 4 weeks, then monthly thereafter.
c. All medication changes will have 3rd and final check by LN's as per facility guidelines.
3. Administrator, LN's and Resident Care Coordinators will be responsible to monitor medication administration records.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate including reasons for use and resident specific PRN parameters for 4 of 4 sampled residents (#s 1, 2, 3 and 5), whose MARs were reviewed. Findings include but are not limited to:
1. Resident 3 was admitted to the facility in 01/2023 with diagnoses including depression.
Review of the resident's 04/01/24 through 05/13/24 MAR identified multiple medications which lacked reason for use.
In an 05/14/24 interview with Staff 1 (Wellness Director) and Staff 4 (RN), it was confirmed Resident 3's MAR lacked documentation of reasons for use for multiple medications.
On 05/14/24, the need to ensure the MAR included reasons for use for each medication was discussed with Staff 1 and Staff 4. They acknowledged the findings.
4. Resident 1 moved from the facility's MCC to the assisted living (AL) community at an undocumented date between 03/2023 and 07/2023 with diagnoses including post-traumatic stress disorder (PTSD), cognitive dysfunction, and chronic pain.
The resident's 04/01/24 to 05/13/24 MAR and current prescriber orders, dated 03/19/24, were reviewed and revealed the following:
a. Multiple scheduled and unscheduled medications lacked reason for use.
b. The following medications lacked medication-specific instructions for administration or resident-specific parameters for PRN dosing:
* Hydrocodone (for pain);
* Acetaminophen (for pain); and
* Voltaren 1% (for pain).
In an interview with Staff 6 (Medication Room Supervisor RCC) on 05/14/24 at 3:23 pm, she confirmed multiple medications did not have a reason for use documented, the PRN pain medications lacked parameters, and the PRN Voltaren lacked medication-specific instructions for administration.
The need to ensure the MAR included reasons for use for each medication, PRN pain medications had resident-specific parameters, and treatments provided resident-specific instructions for unlicensed staff was discussed with Staff 1 (Wellness Director), Staff 4 (RN), Staff 6, and Staff 23 (Regional Wellness Services Director) on 05/16/24. They acknowledged the findings.
2. Review of Resident 2's 04/01/24 through 05/13/24 MAR identified the following:
a. The MAR failed to include clear parameters and instructions to unlicensed staff which of the following medications should be administered first:
* Acetaminophen 500 mg, two tablets every eight hours as needed for pain; and
* Oxycodone 10 mg, half tablet by mouth every four hours as needed for pain.
b. The MAR revealed multiple medications which lacked reason for use.
On 05/13/24, the need to ensure PRN medications included resident specific parameters and instructions for unlicensed staff and the MAR included reasons for use of medications was discussed with Staff 1 (Health and Wellness Director/Administrator), Staff 4 (RN), and Staff 23 (RN/Regional Director of Wellness Director). They acknowledged the findings.
3. Review of Resident 5's 04/01/24 through 05/13/24 MAR revealed multiple medications which lacked reason for use.
On 05/13/24, the need to ensure the MAR included reasons for use of medications was discussed with Staff 1 (Wellness Director), Staff 4 (RN), and Staff 23 (Wellness Director). They acknowledged the findings.
1.
a. All sampled resident medications now have reason for use attached.
b. Resident #2 MAR has been updated with clear parameters related to Acetaminophen vs Codeine administration.
2.
a.Full audit of medications to be completed by 6/28/24 to ensure reason for use is indicated with all medications.
b. Full audit of all PRN medications to be completed by 6/28/24 to ensure that parameters of which medications to be given first is indicated.
c. LN's to monitor this on third check of every medication.
3. This will be monitored weekly x 4 weeks, and then monthly.
4. LN's responsible to monitor at each final check.
Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented as ineffective prior to PRN psychotropic medications being administered for 1 of 1 sampled resident (# 4) who was prescribed as needed psychotropic medications. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 09/2022 with diagnoses including anxiety disorder.
The resident's 04/01/24 through 05/12/24 MAR and prescriber orders were reviewed, and staff were interviewed.
Resident 4 had a physician order for alprazolam 0.25 mg - take one tablet by mouth daily at bedtime as needed for anxiety. The MAR indicated the resident received the PRN medication 22 times between 04/01/24 and 05/08/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication.
On 05/14/24 at 2:29 pm, Staff 13 (MT) was requested to check the computer medication system for direction relating to non-drug interventions to try with Resident 4 prior to administering the PRN alprazolam. Staff 13 confirmed there were no interventions documented in the electronic MAR. This was corroborated with Staff 6 (Medication Room Supervisor/RCC) on 05/14/24 at 3:06 pm. Staff 25 (CG/MT) acknowledged on 05/14/24 at 2:50 pm that he hadn't documented non-pharmacological interventions attempted prior to the administration of the resident's PRN alprazolam.
The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed with Staff 1 (Wellness Director), Staff 4 (RN), Staff 6, and Staff 23 (RN/Regional Wellness Director) on 05/16/24. They acknowledged the findings.
1. Sampled resident psychotropic medications updated with non-pharmacological interventions and indicators on when to give anti anziety medications.
2. Orders for PRN psychotropic medications will be reviewed and interventions included at time of receiving orders. Instructions to document interventions prior to administration to be conducted with med-techs at weekly med-tech meetings.
3. This will be evaluated weekly x4, then monthly and with quarterly pharmacy reviews.
4. RN responsible to lead implementation of interventions and instructions for administration of psychotropic medications.
Based on interview and record review, it was determined the facility failed have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 01/2023 with diagnoses including chronic pain and an overactive bladder. The resident was noted to have experienced a significant change of condition in 04/2024 resulting in higher ADL care needs due to a decline in overall health.
Information provided in the acuity interview and observations made of the resident on 05/15/24 at 9:40 am showed Resident 3 required a minimum of three direct care staff to assist with incontinent care.
Review of the facility's staffing schedule and interview with Staff 6 (Medication Room Supervisor RCC) on 05/15/24 showed the facility consistently staffed two direct care staff during the overnight shifts between 05/01/24 and 05/12/24.
Failure to have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident was discussed with Staff 1 (Wellness Director) and Staff 4 (RN) on 05/15/24. They acknowledged the findings.
1. Resident #3 has been evaluated and moved to higher level ofcare. Service plan was updated prior to the 5/31/24 move out of community.
2. Resident's requiring x2 person transfers will be evaluated for potential transfer to higher level of care. If resident's are required with more than 2 person's transfer the facility will staff as required until higher level of care can be obtained.
3. This will be evaluated weekly x4 then monthly or as needed for increasing care needs.
4. Administrator and resident care coordinator responsible to manage staffing requirements.
Based on observations, interview, and record review, it was determined the facility failed to update the Acuity-Based Staffing Tool (ABST) at least quarterly and with significant change of condition for 1 of 3 sampled residents (#3) and multiple unsampled residents, whose records were reviewed. Findings include, but are not limited to:
The facility was home to 34 residents at the time of survey.
a. Resident 3 admitted to the facility in 01/2023 with diagnoses including chronic pain and an overactive bladder. The resident was noted to have experienced a recent significant change of condition resulting in higher ADL care needs.
Interviews with staff, record review and observations made of the resident on 05/15/24 at 9:35 am found the resident required three staff to assist with incontinent care after experiencing a significant change of condition due to a decline in overall health.
The facility ABST showed numerous ADL care areas which were not reflective of Resident 3's current care needs. The number of staffing minutes noted on the ABST tool did not accurately reflect the amount of time staff spent with Resident 3 providing care in the areas including:
* Assisting with leisure activities;
* Providing treatments(e.g. skin care, wound care, antibiotics); and
* Helping with bowel and bladder management.
b. Review of the ABST identified Resident 3 and multiple other residents whose ABST evaluation had not been updated at least quarterly or with significant changes of condition.
The ABST was not updated at least quarterly and with significant change of condition; therefore, it could not accurately inform the generated staffing plan.
The need to update the ABST whenever there was a significant change of condition and at least quarterly was reviewed with Staff 1 (Wellness Director) and Staff 4 (RN) on 05/16/24. They acknowledged the findings.
1. ABST audit completed by 6/28/2024.
2. Resident Care Coordinator have ongoing access to ABST and will be updated with each care plan meeting held.
3. This will be evaluated weekly with care plans held that week.
4. Resident Care Coordinator and Administrator responsible to monitor and ensure ABST is updated.
Based on interview and record review, it was determined the facility failed to maintain documentation regarding each direct care staff's demonstrated competency and maintain written documentation of all training completed by each employee. Findings include, but are not limited to:
During a review of staff training records on 05/14/24 and 05/15/24, Staff 3 (Business Office Manager) was unable to provide documented evidence that sampled staff administering medications and providing personal care had completed pre-service orientation, pre-service dementia training, and demonstrated competency in all duties they were assigned before working independently with residents, and that sampled long term staff had completed annual training including infection control.
The requirement to maintain written documentation of training completed by each employee was discussed with Staff 1 (Wellness Director), Staff 2 (Memory Care Director), Staff 6(Med Room Supervisor/RCC), and Staff 5 (RCC) on 05/15/24. They acknowledged the findings.
Refer to C 370, C 372, and C 374.
1.
a. Sampled staff completed pre-service orientation and competency checklists immediately.
2.
a. Competency Checklist audit to be completed by 6/21/24
b. Pre-service training completion audit to be completed by 6/21/24.
c. Infection control audit to be completed by 6/21/24.
All named trainings will be provided prior to independently working on the floor going forward, Incumbent staff with incomplete training documentation will be required to complete them prior to 7/15/24.
3. This will be evaluated weekly until all incumbent staff members have completed required training, then will be audited monthly to ensure all training has been completed with newly hired staff.
4. Business office manager responsible to track if trainings are completed.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 14, 21, and 20) completed pre-service orientation and dementia training prior to beginning their job responsibilities and one of two long term staff (#18) completed the Department-approved HCBS training. Findings include, but are not limited to:
Staff training records were reviewed with Staff 3 (Business Office Manager) on 05/14/24. The following was identified:
There was no documented evidence Staff 11 (MT) hired 01/15/2024, Staff 14 (CG) hired 04/08/24, Staff 21 (CG) hired 03/12/24, and Staff 20 (Dietary Aide) hired 03/26/24, completed required pre-service orientation topics and pre-service dementia training prior to beginning job duties.
There was no documented evidence Staff 18 (CG), hired 01/10/23, had completed the Department-approved HCBS training.
The need to ensure staff completed all required pre-service orientation and dementia training prior to beginning job duties and completed the HCBS training was discussed with Staff 1 (Wellness Director), Staff 2 (Memory Care Director), Staff 6 (Med Room Supervisor/RCC), and Staff 5 (RCC) on 05/15/24. They acknowledged the findings.
1. All sampled staff have completed training as required.
2. All staff going forwared will be required to complete full training prior to being independently responsible for their job duties.
3. Audits of employee files for required training certificates will be done weekly for 4 weeks, with final audit on 7/5/24. This will be monitored ongoing each month for all newly hired staff.
4. Business Office Manager to be responsible for tracking of training records. Resident Care Coordinator responsbile to schedule staff for training completion.
Based on interview, and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 11, 14, and 21) had documented evidence of demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:
Staff training records were reviewed with Staff 3 (Business Office Manager) on 05/14/24. The following was identified:
Staff 11 (MT) hired 01/15/2024, Staff 14 (CG) hired 04/08/24, and Staff 21 (CG) hired 03/12/24, lacked documented evidence they had completed all of the required training, demonstrated competency in all job duties, and been trained in First Aid and abdominal thrust training within 30 days of hire.
In an interview with Staff 6 (Med Room Supervisor/RCC) on 5/15/24, she acknowledged Staff 11 had not demonstrated competence in medication pass prior to working independently as a MA Staff 6 agreed to ensure Staff 11 demonstrated competence prior to passing medications independently.
The need to ensure staff completed all required training and demonstrated competency within 30 days of hire was discussed with Staff 1 (Wellness Director), Staff 2 (Memory Care Director), Staff 6 (Med Room Supervisor/RCC), and Staff 5 (RCC) on 05/15/24. They acknowledged the findings.
1. All sampled staff to complete x30 day training requirements by 6/21/24.
2. Full employee file audit to be completed by 6/28/24, any missing trainign to be conducted and completed by 7/15/24.
3. Audits will be monitored weekly until all incumbent staff members have completed required training and provided documentation. Training will be monitored monthly to capture all newly hired staff.
4. Business office manager tracks all training documentation, Administrator responsible to ensure training is complete, Resident care coordinator responsible to schedule training specifically for required training.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term, non-direct care staff (#s 22 and 9) completed required annual infectious disease training. Findings include, but are not limited to:
Staff training records were reviewed on 05/14/24 and 05/15/24.
Staff 22 (Dietary Services Director), hired 06/22/21, and Staff 9 (Housekeeper/Bus Driver), hired 09/06/22, lacked documented evidence of completion of annual infectious disease training based on anniversary date of hire.
The need to ensure all staff completed the required annual infectious disease training was discussed with Staff 1 (Wellness Director) and Staff 2(Memory Care Director) on 05/15/24. They acknowledged the findings.
1. All sampled staff have completed infection control trainings.
2. New hire training will include pre-service infection control training through Oregon Care Partners, ongoing annual training will utilize the Oregon Care Partners training titled "About infection control and prevention."
3. This area will be evaluated weekly x4 weeks to follow up on any staff missing this training. All training will be complete and up to date by 7/15/2024.
4. Business office manager will track all training, department managers responsible to assign and schedule training and ensure it is complete before employee performs job duties independently.
Based on interview and record review, it was determined the facility failed to provide fire and life safety training at least every other month. Findings include, but are not limited to:
Fire and life safety records, reviewed between 10/2023 - 04/2024, revealed fire and life safety training was not documented as completed every other month alternating with fire drills.
In an interview with Staff 8 (Maintenance Director) on 05/14/24, he acknowledged there was no documented fire and life safety training.
On 05/14/24 the need to provide fire and life safety training was reviewed with Staff 1 (Wellness Director). She acknowledged the findings.
1. The facility acknowledges that no fire drill was held in April of 2024.
2. Going forward the facility will utilize the TELS system to track and schedule monthly fire drills in accordance with the rule.
3. This area will be evaluated monthly during CQI meetings to ensure all areas of the rule are met.
4. Maintenance director responsible to manage holding and documenting routine fire drills.
Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:
On 05/13/24, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 8 (Maintenance Director).
Staff 8 reported he did not have documented evidence of annual fire and life safety instruction to residents.
During an interview with a group of seven alert and oriented residents on 05/15/24, they were not aware of general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire.
The need to ensure residents were re-instructed at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire was reviewed with Staff 1 (Wellness Director) and Staff 2 (Memory Care Director) on 05/15/24. They acknowledge the findings.
1. Annual Fire Drill training for residents has been scheduled for July 10th. Facility acknowledges that fire procedures were not reviewed annually.
2. Annual fire and life drills for residents will be scheduled going forward, and discussed with each service plan.
3. This will be evaluated with each quarterly evaluation of residents. One annual training will be done in July of 2024.
4. Resident Care Coordinators and Administrator are responsible to review with each quarterly service plan.
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 610.
Refer to C 610
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material, accessible, maintained in good repair, and all toxic material were secured in locked storage. Findings include, but are not limited to:
1. The exterior of the facility was toured on 05/13/24 through 05/15/24. The following was identified as needing repair:
* Exterior concrete pathways and patios contained multiple drop offs measuring from two to four inches from the concrete to the planting bed surface. These drop-offs created potential hazards for residents that frequently walked the pathway and used the patio.
* The concrete patio and sidewalk around the building had multiple areas of broken concrete creating tripping hazards.
* Areas of the concrete path had settled and shifted creating uneven pathways.
On 5/13/24 at approximately 3:00 pm, a gentleman was observed to fall over the edge of the patio into the planting bed while sitting in the courtyard.
2. The maintenance room/office was noted with an unlocked cabinet of chemicals and cleaners and a cart with chemicals and solvents on 05/14/24. Staff 8 (Maintenance Director) was informed chemicals needed to be secured on 05/14/23 at approximately 9:30 am.
The room was observed unsecured without staff throughout the day on 05/14/24.
The need to secure chemicals was reviewed and the building's exterior was toured with Staff 1 (Wellness Director) and Staff 8 (Maintenance Director) on 05/14/24. They acknowledged the findings.
1.
a. Facility acknowledges the exterior of the facility has drop-offs. Landscaping companies have provided bids for building up areas around building.
b. Concrete replacement bids have been scheduled to repair broken areas of sidewalk, at this time the areas are pointed out with caution tape to identify tripping hazards.
c. The chemicals in the maintenance room now have a lock and are secured, maintenance room will also be locked unless a facility employee is in the office.
2. The areas named will be repaired. The areas will be monitored routinely for ongoing compliance.
3. These areas will be monitored and reported on monthly with CQI meeting, including monthly walk throughs of the building.
4. Maintenance director will be responsbile to maintain areas, and to report to administrator when areas are in need of repair.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were made of hard, smooth material, accessible, and maintained in good repair. This is a repeat citation. Findings include, but are not limited to:
1. The exterior of the facility was toured on 09/23/24 through 09/25/24. Findings include but are not limited to:
*The concrete patio near the facility entrance and sidewalk around the building had multiple areas of broken concrete, creating tripping hazards; and
*Areas of the concrete path in the courtyard had settled and shifted, creating uneven pathways causing tripping hazards.
During an interview on 09/24/24, Staff 30 (Administrator) acknowledged the facility had not yet made repairs to the facility pathways since the re-licensure survey.
On 09/24/25, the need to ensure all exterior pathways were maintained in good repair was discussed with Staff 30. She acknowledged the findings.
1. At this time facility acknowledges the risk related to damage and lifting of sidewalk. The facility has requested multiple bids from different vendors for replacement and repair. The facility will be scheduling repair as able with availability from vendors.
2. The sidewalks and courtyard around the community will be monitored and inspected quarterly with CQI meetings, and as needed for reports of breaks or changes in sidewalks.
3. Quarterly with CQI meetings.
4. Maintenance director will be responsible to observe and report any changes or breakdown in future sidewalks with the administrator as support. The administrator will be responsible to manage repair of current damages done.
10/15/24 Addendum:
To add to our POC:
We have J&N customs has provided a bid, Challis construction has also provided a bid. Both have been submitted to ownership groups for choosing. Each company reports that project work can begin October 28th with completion in 5 days.
Should either of these companies be unable to complete the project prior to compliance date the facility will continue cordon off the areas in the courtyard. This does not restrict access to the courtyard yard for residents, residents are still able to move freely around the area. The facility will also fill in the front sidewalks with cement mix if either company is unable to complete repairs by compliance date.
Thank you,
Emily Taghon
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the interior of the facility was kept free from unpleasant odors and maintained in good repair. Findings include, but are not limited to:
The interior of the facility was toured on 05/13/24 through 05/15/24. A strong, pervasive odor of urine was detected on the north hall of the facility.
In an interview and tour on 05/14/24, Staff 1 (Wellness Director) was aware of the odor and acknowledged it was pervasive.
The flooring in the staff laundry was damaged at the cove base behind the industrial washer and under the hopper in the soiled laundry processing room. There was a build up of matter in the cracks of the flooring.
The flooring was observed with Staff 1 and Staff 8 (Maintenance Director). They acknowledged the damage.
1.
a. Strong urine odor has been addressed with resident, apartment cleaned, carpets cleaned.
b. Laundry room flooring has been deep cleaned.
2. This resident's apartment will be routinely cleaned, with daily incontinence care related to soiled linens and other materials.
The laundry rooms will be monitored monthly with maintenance walk-throughs.
3. The urine smell will be monitored daily as per resident's care plan; the laundry room will be monitored monthly with CQI walk-through of building.
4. Maintenance director will be responsible to manage the cleanliness of laundry rooms. The resident care coordinator is responsible to ensure that care-partners are assisting with urine incontinence of named area.
Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system for security purposes and to alert staff when residents exited the building and to provide access to a public telephone in a private area. Findings include, but are not limited to:
1. The facility was toured on 05/13/24 through 05/15/24. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents exited the building.
The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (Wellness Director) and Staff 8 (Maintenance Director) on 05/16/24. They acknowledged the findings.
2. Resident 1 admitted to the facility in 2023 with diagnoses including cognitive dysfunction and chronic post-traumatic stress disorder.
The resident's service plan, dated 12/13/23, was reviewed, observations of the resident were made, and interviews with the staff and the resident were conducted.
On 05/13/24, 05/14/24, and 05/16/24, Resident 1 was visualized requesting to make a phone call or using the phone at the concierge's desk in the presence of the concierge. This phone was located at the entrance to the facility and was used by the concierge to make and receive phone calls on behalf of the facility.
During an observation of Resident 1's room on 05/15/24, there were no phones visible. This was confirmed with Resident 1 who stated s/he thought he used to have a cell phone, but now used the phone at the front desk to make phone calls.
On 05/16/24 at 9:44 am, Resident 1 was observed requesting to make a phone call and was told by Staff 19 (CG/MT/Former Concierge) s/he needed to wait to make his/her call until the concierge was finished. At 9:45 am on 05/16/24, Staff 19 reported the front desk phone was the only phone currently available for residents to make personal calls. Previously, the facility had a cell phone residents used; however, access to that phone ceased following the change of ownership. She continued to state she encouraged residents to make phone calls after business hours, and she acknowledged the lack of privacy for residents.
The need to ensure the facility has a local access public telephone in a private area that allowed residents to conduct a private conversation was discussed with Staff 1 (Wellness Director), Staff 4 (RN), Staff 6 (Med Room Supervisor/RCC), and Staff 23 (Regional Wellness Director) on 05/16/24. They acknowledged the findings.
1.
a. Door alarms are installed.
b. Phone for residents bids have been requested from phone company.
2. The door alarms are a one time permanent installation, with monitoring to be done routinely to ensure they are in good working order.
The phone will be a one time installation for permanent use.
3. The door alarms will be evaluated on a monthly basis to ensure they are in good working order.
The phone will be one-time installation.
4. Maintenance director and administrator to ensure that these elements are in place. Maintenance director responsible to ensure door alarms are in working order.
H 1515: Physical Setting Individual Accessible: OAR 411-004-0020 (2)(b) (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.