The findings of the re-licensure survey conducted 11/28/22 through 11/30/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first revisit to the re-licensure survey of 11/30/22, conducted 05/09/23 through 05/11/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services.
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 11/30/22, conducted 07/27/23 through 07/28/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services.
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 revisit to the re-licensure survey of 05/11/23, conducted 10/11/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.
2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including history of pressure ulcers and edema.
Resident 2's quarterly evaluation dated 09/21/22, was not reflective of the resident's current health status in the following areas:
* Bilateral edema and use of compression stockings; and
* Previous skin injuries and chronic ongoing skin concerns related to skin cancer diagnosis.
The need to ensure evaluations were reflective of the residents' current health status was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 08/2022 with diagnoses including history of fall with hip fracture.
Resident 4's 30 day evaluation, dated 09/26/22, was not reflective of the resident's current status in the following areas:
* Speech and communication; and
* Outside services and hospice admission on 09/05/22.
The need to ensure evaluations were reflective of the residents' current health status was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident evaluations contained sufficient and/or accurate information, were reflective of resident care needs, were updated 30 days following a resident's move in and at least quarterly or with a significant change of condition for 3 of 6 sampled residents (#s 2, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.
a. Resident 3's initial evaluation, dated 05/28/22, contained inaccurate or incomplete information in the following areas:
* Use of an inhaler;
* Assistance with ADL's; and
* Alcohol use.
b. There was no documented evidence a 30 day evaluation had been completed on or around 07/22/22.
c. On 08/17/22 Resident 3 fell while walking outside the facility and was diagnosed with a right rib fracture. Resident 3 had a subsequent fall while intoxicated on 10/27/22 which resulted in a right "distal radial" (wrist) fracture.
A facility "Evaluation and Service Planning" form was completed for both the 08/17/22 and 10/27/22 falls. Incomplete or inaccurate information was identified in the following areas:
* Use of an inhaler;
* Assistance with ADL's;
* Alcohol use;
* Safety checks; and
* Assistance needed during an evacuation.
The need to ensure resident evaluations contained sufficient and/or accurate information, were updated 30 days following a resident's move in and with a significant change of condition was discussed with Staff 1 (General Manager), Staff 2 (Health and Wellness Director) and Staff 3 (Director of Regional Operations) on 11/28/22 and 11/29/22. They acknowledged the findings.
OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation
Resident 2,3, and 4 has been reassessed and service plan was updated to reflect complete and accurate Resident care needs.
Prior to the resident move-in Health and Wellness Director and General Manager will review evaluation and service plan to ensure it reflects all evaluation elements. Evaluations will be reviewed 30 days after the initial move-in and quarterly.
Evaluation training was held by H&W Director and Operations Director. Evaluation will be audited monthly by Health and Wellness Director.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff, and updated for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 2022 with diagnoses including Parkinson's disease.
Observations and interviews with Resident 1 and Witness 1 (Family Member) during the survey, and review of the clinical record including the service plan, dated 11/06/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:
* Specific ADL care needs;
* Bathing assistance;
* Bed devices;
* Medication administration;
* Housekeeping and laundry services;
* Activity preferences;
* Private caregiver duties; and
* Transfer assistance one to three staff needed.
The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 2 (Health and Wellness Director) on 11/29/22. She acknowledged the findings.
2. Resident 5 was admitted to the facility in 08/2019, with diagnoses including dementia and hypertension.
Observations, interviews and review of Resident 5's clinical records revealed the service plan, with the most recent "effective date" of 11/13/22, was not reflective of the resident's care needs and/or did not provide clear direction to staff in the following care areas:
* Use of pendant call system;
* Private caregiver schedule and duties; and
* Fire evacuation needs related to the resident's inability to navigate stairs.
During an interview on 11/28/22, Resident 5 stated s/he did not have a call pendant, only an emergency pull cord and stated s/he had requested a call pendant in the past but had not received one. No pendant call light was observed in the resident's room.
The need to ensure service plans were reflective of residents' care needs and provided clear direction to staff was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 03/2020 with diagnoses including history of pressure ulcer.
Observations and interviews with Resident 2 during the survey, and review of the service plan, dated 09/21/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following area:
* Chronic skin concerns related to cancer diagnosis.
The need to ensure the service plan was reflective of Resident 2's current health status and care needs was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
4. Resident 4 was admitted to the facility in 08/2022 with diagnoses including history of fall with fracture.
Observations and interviews with Resident 4 and a review of the current service plan dated 09/26/22 were conducted during the survey.
a. The current service plan was not reflective of the resident's status and care needs and lacked clear direction to staff on the delivery of services in the following areas:
* Family member provided care with toileting, ambulation, housekeeping, grooming, dressing, and escorts to and from activities and dining;
* Hospice aide provided care with bathing, grooming, personal hygiene, and skin care;
* Outside providers;
* Use of side rails and precautions related to the use of the device;
* Sleep routine; and
* Behaviors, including resistive to care and interventions.
b. The service plan, dated 09/26/22, was not followed by staff in the following areas:
* Incontinent care every two hours;
* Repositioning every two hours to prevent bed sores; and
* Assist with compression stockings every morning and evening.
During an observation on 11/30/22, Resident 4 was not wearing compression stockings.
During an interview on 11/28/22, Staff 24 (Resident Assistant I) stated, "we don't do anything for [him/her], [his/her] daughter is always here and provides most of the care. Sometimes I help [him/her] into bed if [his/her] daughter has already left. [S/he] likes to stay up late at night and doesn't always want to get into bed so I communicate with the night shift letting them know [s/he] is still awake so they know to check on [him/her]."
The need to ensure the service plan was reflective of Resident 4's current health status and care needs, provided clear instructions to staff and was followed was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
5. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.
Review of the resident's service plan, with the most recent "effective date" of 10/08/22, interviews with staff and observations of the resident showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not followed in the following areas:
* Depression signs and symptoms;
* Activity preferences;
* Pain - nonverbal signs of pain and non-drug interventions;
* Fall interventions;
* Frequency of safety checks;
* Alcohol use;
* Monthly weights;
* Balance training;
* Safety checks;
* Transfer assistance; and
* Walking, wandering halls throughout the day.
There was no documented evidence the service plan had been reviewed or updated within 30 days of admission.
The need to ensure resident service plans were accurate, updated with changes, provided clear direction to staff on the delivery of services, and were followed was reviewed with Staff 1 (General Manager) Staff 2 (Health and Wellness Director) and Staff 3 (Director of Regional Operations) on 11/28/22 and 11/29/22. They acknowledged the findings.
OAR 411-054-0036 (1-5) Service Plan: General
Resident 1,2,3,4,5 has been evaluated, and current health needs, clear direction regarding the delivery of services has been updated and is now reflective of resident care needs.
Resident 5 has received a call pendent, the service plan is reflective of the private caregiver's schedule and duties, evacuation needs applied.
Service Plan development, training was conducted by H&W Director with the nursing team. Service plans will be audited monthly and reviewed quarterly by Health and Wellness Director.
The General Manager is responsible to see that the corrections are completed and monitored.
2. Resident 10 was admitted to the facility in May of 2021 with diagnoses including a stroke.
Observations of the resident, interviews with staff, and review of the service plan dated 03/20/23 showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas:
* Side rail use;
* Home health Occupational Therapy; and
* Weight loss interventions and meals provided by family.
The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (Health and Wellness Director) and Staff 31 (RN) on 05/11/23. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 7 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in 09/2019 with diagnoses including localized edema, restless leg syndrome and Parkinson's disease.
Interviews with resident and staff, and review of the current service plan, dated 05/05/23, revealed Resident 7's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:
* Hearing and use of assistive devices;
* Transfers;
* Dental status; and
* Skin and wound condition monitoring.
The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 2 (Health and Wellness Director) and Staff 31 (RN) on 05/11/23 at 1:05 pm. They acknowledged the findings. No further information was provided.
OAR 411-054-0036 (1-4) Service Plan: General
Resident 7,8,9,10 has been evaluated, and current health needs, and clear direction regarding the delivery of services has been updated and is now reflective of resident care needs.
Resident 7 service plan is reflective hearing and assistive devices, transfers, dental status, Skin, and wound monitoring. Resident 10 has been evaluated to reflect side rail use, home health therapy, and weight loss interventions.
Service Plan development, review, and re-training were conducted by H&W Director with the new nursing team. Service plans will be audited and reviewed quarterly by Health and Wellness Director.
The General Manager is responsible to see that the corrections are completed and monitored.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 2 sampled residents (#s 7 and 8.) This is a repeat citation. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in 03/2017.
The resident's 07/24/23 evaluation, 07/25/23 service plan and temporary service plans were reviewed and revealed s/he was recently re-diagnosed with skin cancer and noted staff were to monitor the condition for signs of worsening when assisting the resident with bathing.
The service plan was not reflective of the resident's current status and needs and did not give clear instruction to the staff regarding the resident's skin condition.
The need to ensure Resident 7's service plan was reflective of his/her current status and needs and provided clear instruction to staff was discussed with Staff 2 (Health and Wellness Director) and Staff 31 (RN) on 07/28/23. They acknowledged the findings.
2. Resident 8 was admitted to the facility in 08/2019 with diagnoses including osteoarthritis.
In the entrance conference on 07/27/28, the resident was identified as using bilateral side rails on his/her bed.
Observations of the resident and the resident's room revealed the side rails were in the up position throughout the survey.
Resident 8's most recent service plan included an entry dated 08/08/19 noting his/her side rails had been removed and were not in use.
The service plan lacked documentation related to the use and precautions of the device including clear instruction for staff.
The need to ensure Resident 8's service plan was reflective of his/her needs and included clear instruction to the staff was discussed with Staff 2 (Health and Wellness Director) and Staff 31 (RN) on 07/28/23. They acknowledged the findings.
OAR 411-054-0036 Service Plan; General
Resident 7 and 8 has been evaluated, service plans are now reflective of the resident's health care needs, clear direction has been provided to staff in the service plan.
Service Plan development, training was conducted by H&W Director with the nursing team. Service plans will be audited and reviewed quarterly by Health and Wellness Director.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with, or who provided services, for 2 of 6 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:
There was no documented evidence the current service plans for Residents' 2 and 3 were developed by a service planning team.
On 11/29/22, the need to ensure service plans were developed by a service planning team and were documented was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN). They acknowledged the findings.
OAR 411-054-0036 Service plan; Service Planning team
Residents 2 and 3 now reflect signatures from the service planning team and representative of the resident. Training was conducted with the nursing team and service plan designees, and how a service plan team is developed and what it consists of has been reviewed. H&W Director will perform monthly audits and review service plans to ensure all signatures are received when a service plan evaluation or assessment has been conducted.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure resident changes of condition were evaluated and referred to the facility RN as necessary, resident specific interventions were determined, documented, communicated to staff and monitored for effectiveness, and conditions were monitored per the residents' evaluated needs with weekly progress noted until the condition resolved for 4 of 6 sampled residents (#s 2, 3, 4 and 5) whose records were reviewed. Resident 5 experienced severe and ongoing weight loss. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 08/2019, with diagnoses including dementia, hypertension, and edema.
The service plan with current effective date of 11/13/22, noted the resident required staff assistance with ADLs including ambulation, transfers, toileting and was able to eat independently.
Review of Resident 5's clinical records including MARs dated 09/01/22 through 11/27/22, weight records dated 06/01/22 through 11/27/22, progress notes, evaluations and service plans dated 09/17/22 through 11/28/22 identified Resident 5 experienced the following significant changes of condition:
a. Weight records showed Resident 5 experienced a severe and ongoing weight loss between 08/26/22 and 11/30/22.
The following weights were documented in Resident 5's weight record:
* 08/26/22 - 128 pounds;
* 09/26/22 - 119.2 pounds;
* 10/01/22 - 116 pounds;
* 11/25/22 - 112.8 pounds; and
* On 11/30/22 - 110 pounds.
* Between 08/26/22 and 09/26/22 the resident experienced a severe weight loss of 8.8 pounds or 6.87% loss in total body weight over one month; and
* Between 08/26/22 to 11/25/22 the resident experienced a 15 pound or 11.87 % loss in total body weight over three months.
Observations during lunch meals on 11/28/22 and 11/29/22, noted on both days, the resident consumed 100% of a small bowl of soup.
There was no documented evidence the facility evaluated Resident 5's severe weight loss, determined timely interventions, referred to the facility RN and there was no documented evidence the facility monitored the resident's continued weight loss or effectiveness of interventions when the resident continued to lose a severe amount of weight.
The need to ensure resident changes of condition were evaluated and referred to the facility RN and resident specific interventions were determined and documented, and conditions were monitored per the residents' evaluated needs was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
b. A review of the clinical record revealed Resident 5 had the following skin concerns:
A review of a temporary service plan dated 10/25/22, Staff 5 (RN Consultant) documented Resident 5 had "3 scattered stage 2 pressure ulcers on left buttock and 2 stage 2 pressure ulcers on right buttock. Resident has been lying on [his/her] back in bed all hours of day and night since returning from the hospital." Staff 5 sent a fax to the resident's physician requesting orders for wound treatment to include application of barrier cream TID and PRN and instructed staff to reposition the resident TID.
* On 11/02/22, Staff 5 documented "bilat buttocks with stage 2 pressure ulcers approx. 1.5cm x 1cm with blanchable redness on right and non-blanchable redness of left." Staff 5 instructed staff to continue with current wound treatments.
* On 11/08/22, staff documented the resident reported "severe soreness and some pain from the pressure sores on [his/her] bottom."
* On 11/16/22, Staff 5 documented the "buttock pressure ulcer had worsened. Right buttock with un blanchable redness measuring approx 6cm x 4cm with open areas." The RN noted she left a message with the home health provider to ask about what treatment orders had been recommended and staff were to continue current treatment orders until home health provided new treatment orders.
* On 11/22/22 HH documented their were no open areas.
* During an interview on 11/29/22, Resident 5 stated that s/he had recently been in the hospital and had been staying in bed a lot because s/he had been in pain because of sores on his/her backside but was happy because the sores were finally getting better and s/he had recently been able to walk to his/her mail box with a walker and assistance from a caregiver.
There was no documented evidence the facility implemented the wound treatment from 10/25/22 through 11/11/22 and the facility failed to review the interventions for effectiveness.
The need to ensure resident changes of condition and effectiveness of interventions were monitored per the resident's evaluated needs was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
c. Resident 5 had the following short term change of condition:
* On 10/06/22, An order for Nystatin mouth rinse five times a day for oral fungal infection was added to Resident 5's MAR.
* On 10/11/22, staff documented the resident "was still having difficulties swallowing."
* On 10/26/22, staff documented the resident's mouth was "still sensitive, sore, and contained blistering."
* On 10/27/22, staff documented the resident complained of soreness in his/her mouth.
* On 10/29/22, staff documented the resident "stated [his/her] mouth was really bothering [him/her]."
* On 11/10/22, Resident 5's MAR noted the order for Nystatin mouth rinse had been discontinued.
There was no documented evidence the facility monitored the effectiveness of the oral treatment Nystatin mouth rinse at least weekly.
The need to ensure resident changes of condition and effectiveness of interventions were monitored at least weekly was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including pressure ulcers.
Observations of the resident, interviews with staff, review of the service plan dated 09/21/22, and temporary service plans were reviewed during the survey.
Resident 2 had the following changes of condition:
* 08/05/22 Pressure wound on buttocks; and
* 10/18/22 Skin graft (surgical procedure) to left forearm and forehead.
During an observation and interview on 11/29/22 with Resident 2, the resident's left forearm and forehead were observed to be dry and scabbed. The resident reported, s/he no longer received wound care from home health and s/he doesn't currently have pressure wounds.
During an interview on 11/29/22, with Staff 5 (RN Consultant), it was reported that she was unaware of the resident's skin injuries.
Temporary Care Plans noted Staff 6 (Health and Wellness/LPN) observed the wound on the resident's buttock on 09/02/22, 09/10/22, 09/17/22, and 11/05/22.
Temporary Care Plans noted Staff 6 observed the resident's left forearm wound on 10/15/22, 10/29/22 and 11/05/22, however, there was no documented evidence the facility evaluated and monitored the resident's skin graft on the forehead.
There was no documented evidence the facility determined and documented what action or intervention was needed for the resident, communicated the intervention to staff, monitored the resident's skin with weekly progress noted until the condition resolved and referred the change of condition to the RN for assessment, as required.
The need to ensure the facility determined and documented what action or intervention was needed for the resident, communicated the intervention to staff, monitored the resident's condition with weekly progress noted until the condition resolved and referred the change of condition to the RN, as necessary, was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
3. Resident 4 was admitted to the facility in 08/2022 with diagnoses including history of fall with fracture.
Observations of the resident, interviews with staff, review of the service plan dated 09/26/22, temporary service plans, incident investigations and progress notes dated 09/01/22 through 11/19/22 were reviewed.
Resident 4 had the following evaluated care needs and short term changes of condition:
* On 09/01/22 - behavior change;
* On 09/26/22 - lower left leg edema and pain;
* On 10/6/22 - fall "slide from chair to floor";
* On 10/08/22 - behavior change;
* On 10/17/22 - agitation and mood change;
* On 11/13/22 - unable to bear weight, required two person assist;
* On 11/19/22 - refusal of care/behavior change; and
* On 11/24/22 - fall.
There was no documented evidence the facility monitored the resident's leg pain and edema per the resident's evaluated condition and there was no documented evidence the facility determined and documented what actions or interventions were needed for the resident's short term changes in condition, communicated the interventions to staff, and monitored the resident's changes in condition with weekly progress noted until the conditions resolved.
The need to ensure the facility monitored resident's per evaluated care needs, determined and documented what action or intervention was needed for changes in condition, communicated the intervention to staff, monitored the resident's condition with weekly progress noted until the condition resolved was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.
Review of Resident 3's 05/31/22 service plan, 09/08/22 through 11/23/22 progress notes, temporary service plans and interviews with staff revealed the following:
The Resident's 05/31/22 service plan and subsequent updates and evaluations stated the resident received cueing from staff for grooming, and escorts to and from the dining room and activities. Resident was independent in all other ADL's.
On 10/26/22 the resident fell while intoxicated and was diagnosed with a right "distal radial" (wrist) fracture.
A "Temporary Plan of Care" (TSP) was written on 10/27/22 and noted a list of "expected outcomes" which included:
* Ask resident regarding pain level;
* Balance training;
* Mobility: To remain safe while transferring with assistance; and
* Resident will accept assistance.
There was no documented evidence the facility consistently monitored the residents pain level, evaluated the residents balance, conducted balance training, evaluated for increased care needs as a result of the arm fracture, or the resident required assistance with transfers and was resistant to care. There was also no documented evidence the facility had evaluated previous fall interventions or referred the change of condition to the facility RN for assessment.
During an interview, 11/29/30, Staff 2 (Health and Wellness Director) confirmed the "Expected Outcomes" were not specific to Resident 3, no new fall interventions had been developed after the 10/26/22 fall, and the facility RN had not completed a significant change of condition assessment.
The need to ensure the facility determined and documented resident specific actions or interventions, consistently monitored residents based on their condition and referred significant changes of condition to the facility RN was discussed with Staff 1 (General Manager) Staff 2, and Staff 3 (Director of Regional Operations) on 11/28/22 and 11/29/22. They acknowledged the findings. No further information was provided.
OAR 411-054-0040 (1-2) Change of Condition and Monitoring
Residents 2,3,4,and 5 have been reassessed and service plans updated to reflect their change of condition.
Health and Wellness Director and RN will review notes, weights, incident reports, and alerts, daily and will notify Dr/Home Health when changes are identified, temporary service plans will be in place. Change of Condition assessment will be performed by RN and Health and Wellness Director, service plan will be updated to reflect changes of conditon. Service Planning and Significant Change of Condition training was provided conducted by H&W Director & Corporate RN with nursing team. Changes of condition service plans will be audited when completed by Health and Wellness Director or General Manager using CBC service plan audit tool for all change of conditions. The General Manager is responsible to see that the corrections are completed and monitored.
Based on observation, interview, and record review, it was determined, the facility failed to ensure changes of condition were evaluated and referred to the RN as necessary for 1 of 2 sampled residents reviewed for weight loss (#10). This is a repeat citation. Findings include but are not limited to:
Resident 10 was admitted to the facility in May of 2021 with diagnoses including a stroke.
Review of the current physician orders and 05/2023 MAR showed the resident received a nutritional supplement twice a day as a weight loss intervention.
Resident 10's weight records noted the following:
* 03/05/23 75.4 pounds;
* 03/09/23 74.6 pounds; and
* 04/04/23 70.4 pounds.
The resident lost 4 pounds or 5.6% of his/her body weight. The loss of over 5% of body weight in one month constituted a significant change of condition, and required a timely RN assessment.
There was no documented evidence the facility evaluated Resident 10's weight loss, determined the effectiveness of interventions, and referred to the facility RN for a timely assessment.
The change of condition assessment was not completed by an RN until 05/05/23, 29 days after the 04/04/23 weight loss was recorded. The RN assessment included the interventions of weekly weights, alert charting to monitor intake, and offering the nutritional supplement earlier in the evening at the request of Resident 10.
The surveyor requested Resident 10's weight during survey, and on 05/11/23 weight was 73.4 pounds, a 3 pound weight gain from the previous weight.
Resident 10 was observed during two meals. Resident 10 was observed eating a meal of chicken and vegetables on 05/09/23, with greater than 50% intake
and a meal prepared by a friend in his/her apartment on 05/10/23, with greater than 75% intake.
The requirement to evaluate a change of condition and refer to the facility RN for assessment was discussed in an interview on 05/11/23 with Staff 2 (Health and Wellness Director) and Staff 31 (RN Health Services Director). They acknowledged the findings.
OAR 411-054-0040 (1-2) Change of Condition and Monitoring
Resident 10 has been reassessed, service plan updated to reflect Resident 10's needs.
Full-time RN has been hired, Health and Wellness Director and RN will review weights weekly, and temporary service plans will be in place when needed. Change of Condition assessment will be performed timely by RN and Health and Wellness Director and the service plan will be updated as needed. Service Planning and Significant Change of Condition training was conducted by H&W Director & Corporate RN with community RN. Service plans will be audited monthly by Health and Wellness Director or General Manager using CBC service plan audit tool for all changes of conditions. The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status, interventions made as a result of the assessment, and/or the RN provided intermittent nursing services for 4 of 4 sampled residents (#s 2, 3, 4, and 5) reviewed for significant changes of condition. Resident 5 experienced severe and ongoing weight loss. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 08/2019, with diagnoses including dementia, hypertension, and edema.
a. Review of Resident 5's MAR dated 09/01/22 through 11/27/22, weight records dated 06/01/22 through 11/27/22, progress notes, evaluations and service plans dated 09/17/22 through 11/28/22, identified Resident 5 experienced a severe and ongoing weight loss between 08/26/22 and 11/28/22.
* Between 08/26/22 and 09/26/22 the resident experienced a severe weight loss of 8.8 pounds or 6.87% loss in total body weight over one month; and
* Between 08/26/22 to 11/25/22 the resident lost 15 pounds or 11.87 % loss in total body weight over three months.
The lack of an RN assessment which documented resident status, findings and interventions made as a result of the assessment resulted in Resident 5's continued weight loss.
The need to ensure significant changes of condition were assessed by an RN and the assessment included documentation of findings, the resident's status and interventions made as a result of the assessment was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
Refer to C270, example 1a.
b. Resident 5's clinical record revealed the following:
* On 10/25/22, Staff 5 (RN Consultant) documented Resident 5 had "3 scattered stage 2 pressure ulcers on left buttock and 2 stage 2 pressure ulcers on right buttock.
* On 11/02/22, Staff 5 documented "bilat buttocks with stage 2 pressure ulcers approx. 1.5cm x 1cm with blanchable redness on right and non-blanchable redness of left."
The RN's initial assessment of the wounds on 10/25/22, noted five pressure wounds and directed staff to apply barrier cream BID. The follow up RN assessment on 11/02/22 did not provide information related to the status of all previously identified wounds and there was no documented evidence the RN provided intermittent nursing services to care for the wounds until home health started on 11/09/22.
The need to ensure RN assessments for significant changes of condition were reflective of resident status, findings and interventions made as a result of the assessment and the RN provided intermittent nursing services was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
Refer to C 270, example 1b.
2. Resident 2 was admitted to the facility in 03/2020 with diagnoses including history of pressure wounds.
Interview with Resident 2 and staff and a review of the clinical record including, service plan dated 09/21/22, temporary care plans and outside provider notes identified the resident had the following significant changes of condition:
* On 08/05/22, pressure wound on the buttocks; and
* On 10/18/22, skin graft to the left forearm and forehead.
The skin wounds represented significant changes in condition which required an RN assessment.
There was no documented RN assessment which included documented findings, resident status, and interventions made as a result of this assessment.
The need to ensure the facility RN completed an assessment for all resident's with significant changes of condition was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
Refer to C 270, example 2.
3. Resident 4 was admitted to the facility in 08/2022 with diagnoses including history of fall with fracture.
Interview with Resident 4 and staff and a review of the clinical record including, service plan dated 09/26/22, temporary care plans and outside provider notes identified the resident had the following significant change of condition:
* On 09/05/22, admission to hospice services.
Resident 4's admission to hospice represented a significant change in condition which required an RN assessment.
There was no documented RN assessment which included documented findings, resident status, and interventions made as a result of this assessment.
The need to ensure the facility RN completed an assessment for all resident's with significant changes of condition was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.
A review of Resident 3's clinical record indicated the following:
On 10/27/22 the resident fell while intoxicated and was diagnosed with a right "distal radial" (wrist) fracture. Resident 3's fracture constituted a significant change of condition which required an RN assessment.
There was no documented evidence Staff 5 (RN Consultant) had completed a significant change of condition assessment, which included documented findings, resident status, and interventions made as a result of the assessment.
On 11/23/22, Staff 5 documented on a "Temporary Plan of Care" "Will see resident next week for a full assessment ..."
The need to ensure an RN assessment was completed related to significant changes in condition which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (General Manager) Staff 2 (Health and Wellness Director) and Staff 3 (Director of Regional Operations) on 11/28/22 and 11/29/22. They acknowledged the findings.
OAR 411-054-0045 (1) (a-f)(A)(C-F)
Resident Health Services
Resident 2,3,4,5 has been reassessed for Significant Change of Condition by RN, the service plan updated to reflect this and audited to ensure all changes are found and noted by RN.
Health and Wellness Director and RN will review notes, incident reports, and alerts daily and will have assessment and service plan updates completed for all significant changes of conditions within 48 hours.
Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team.Changes of condition service plans will be audited when completed by Health and Wellness Director or General Manager using CBC service plan audit tool for all change of conditions. The General Manager is responsible to see that the corrections are completed and monitored.
Based on observation, interview, and record review, it was determined the facility failed to conduct a timely RN assessment for 1 of 1 sampled resident (#10) who experienced a significant change of condition related to weight loss. This is a repeat citation. Findings include, but are not limited to:
Resident 10 was admitted to the facility in May of 2021 with diagnoses including a stroke.
Review of the current physician orders and 05/2023 MAR noted the resident received a nutritional supplement twice a day.
Resident 10's weight records noted the following:
* 03/05/23 75.4 pounds;
* 03/09/23 74.6 pounds; and
* 04/04/23 70.4 pounds.
The resident lost 4 pounds or 5.6% of his/her body weight. The loss of over 5% of body weight in one month constituted a significant change of condition, and required an RN assessment.
The RN assessment of the change of condition was not completed until 05/05/23, 29 days after the 04/04/23 weight loss was recorded.
Resident 10 experienced a significant change of condition related to weight loss without a timely RN assessment. In an interview on 05/11/23 with Staff 2 (Health and Wellness Director) and Staff 31 (RN Health Services Director) they acknowledged the findings.
Refer to C270.
OAR 411-054-0045 (1) (a-f)(A)(C-F)
Resident Health Services
Resident 10 has been reassessed for Significant Change of Condition by RN, service plan updated to reflect this. Health and Wellness Director and RN will review notes, incident reports, and alerts daily and will have assessment and service plan updates completed for all significant changes of conditions within 48 hours.
Service Planning and Significant Change of Condition training was conducted by H&W Director and Corporate RN with the nursing team. Health and Wellness Director will audit completed service plans monthly. The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
2. Resident 5 was admitted to the facility in 08/2019, with diagnoses including dementia, hypertension, and edema.
Review of Resident 5's clinical records and outside service provider notes revealed home health services for wound care began on 11/07/22.
The facility was not able to locate the outside provider notes dated 11/07/22 - 11/21/22. The home health provider faxed the notes to the facility on 11/30/22, per the surveyors request. Review of the home health notes revealed there was no documented evidence the facility was aware of and/or implemented the following recommendation made by the home health provider:
* 11/09/22- Wound care orders for stage II pressure wounds- Triad paste, cover with foam dressing daily and apply silicone barrier ointment or zinc barrier cream to intact skin of buttocks BID and with episodes of incontinence;
* 11/09/22- Encourage resident to float heels related to risk for pressure injury;
* 11/21/22- Remind resident to sit upright for meals; and
* 11/22/22- Suggest "hospital bed with group 2 mattress overlay".
The need to ensure the facility had a system in place for outside providers to leave written information in the facility that addressed the on-site services provided and any recommendations from outside providers were reviewed and followed was discussed Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/30/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care and failed to ensure recommendations from outside providers were followed for 2 of 5 sampled residents (#s 4 and 5) who received outside services. Findings include, but are not limited to:
1. Resident 4 admitted to the facility in 08/2022 with diagnoses including history of fall with fracture.
During the entrance conference interview on 11/28/22, it was reported the resident received services from hospice.
a. A review of the clinical record noted the following:
* Resident 4 was admitted to hospice on 09/05/22 and received services twice per week from a hospice aide and nursing services once per week;
* There was a total of seven hospice aide notes in the resident's chart from 09/05/22 through 11/27/22; and
* There was no documented evidence the facility had received any clinical nursing care plans since hospice admission.
During an interview on 11/30/22 at 10:04 am, Staff 7 (Health and Wellness Coordinator), reported "I was asked two days ago to contact them because only the bathe aide was leaving notes."
b. The following hospice recommendation was not communicated to staff or followed:
On 10/06/22 a hospice physician's order noted to provide two hour checks for a "brief change and repositioning to prevent bed sores."
Observations on 11/29/22 in the afternoon and 11/30/22 in the morning revealed staff did not check on the resident every two hours to provide repositioning and incontinent care.
During an interview on 11/29/22, Staff 24 (Resident Assistant I) reported, "we don't do anything for [him/her], [his/her] daughter does most of the work, she is here all the time. I just remind [him/her] to hydrate, elevate [his/her] legs and call if [s/he] needs anything."
The need to ensure the facility had a system in place for outside providers to leave written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care and ensure recommendations from outside providers were followed was discussed Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/30/22. They acknowledged the findings.
OAR 411-054-0045 (2) Res Hlth Srvc: On- and Off-Site Health Srvc
Resident 4 and 5 has been evaluated, service plan updated reflect current needs and home health reccommendations. Coordinators and Nurses have been trained to request all notes from Home Health during their visit, if unable to obtain they will call HH to obtain notes.
Home Health/Outside Provider notes will be reviewed daily by LPN and Health and Wellness Director during clinical meetings, recommendations will be updated in the service plan. Coordination of Care training was provided by Health and Wellness Director. Service Plans with home health support will be audited during daily meetings to ensure HH recommendations are incorporated and updated in service plans.
Health and Wellness Director will be responsible for monitoring compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 08/2019, with diagnoses including dementia, hypertension, and edema.
Review of Resident 5's clinical records including MARs dated 09/01/22 - 11/27/22 and physician orders identified the following:
* On 10/25/22, the facility documented Resident 5 had multiple pressure wounds on bilateral buttocks. The facility faxed the resident's physician and requested treatment orders for barrier cream TID and PRN.
* On 11/06/22, the facility faxed the physician and requested wound treatment orders again.
* On 11/08/22, the physician responded and stated "I sent Rx for barrier cream last week."
The facility failed to obtain the treatment order and update the MAR until 11/12/22.
The need to ensure adequate professional oversight of the medication and treatment administration systems was discussed with Staff 2 (Health and Wellness Director) on 11/30/22. No further documentation was provided.
2. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:
C 305: Systems: Resident Right to Refuse;
C 310: Systems: Medication Administration; and
C 325: Systems: Self Administration of Medication.
The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (General Manager), Staff 2 (Health and Wellness Director), Staff 3 (Director of Regional Operations) and Staff 8 (Health and Wellness Manager) during the exit interview on 11/30/22. They acknowledged the findings.
OAR 411-054-0055 (1)(a) Systems: Medications and Treatments
Resident 5 has been reassessed, continued RN monitoring for change of condition, and scheduled treatments monitored to ensure care is timely and effective.
Health and Wellness Manager has been trained to provide administrative oversight of medication and treatment administration systems. In-service conducted with unlicensed staff on medication policy; reviewing orders throughout the shift and ensuring both fax locations are checked. The designee, coordinator, and nurse will provide follow-up every 24, 48, and 72 hours to ensure communication is delivered and received timely, Health and Wellness Manager will oversee this process and audit weekly.
Health and Wellness Director will be responsible for monitoring compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to medication/treatments orders for 1 of 1 sampled resident (# 5) who had documented medication and/or treatment refusals. Findings include, but are not limited to:
Resident 5's MAR dated 11/01/22 through 11/27/22 was reviewed during survey. The MAR identified numerous occasions when the resident refused multiple medications and/or treatments.
There was no documented evidence the facility consistently notified the physician when the resident refused numerous medications and/or treatments between 11/01/22 through 11/26/22.
The need to ensure the facility notified physicians of medication and/or treatment refusals was discussed with Staff 1 (Health and Wellness Director) on 11/30/22. She acknowledged the findings.
OAR 411-054-0055 (1) (j-k) Systems: Resident Right to Refuse
Resident 5's PCP has been notified of all refused and missed medications.
Med techs have been re-trainined on proper protocol for resident refusal of medication and how to properly doument details in the MAR, notifying the Health and Wellness Director and the residents physician. All Medication refusals will be audited and reviewed daily by Health and Wellness Director or RN.
Health and Wellness Director will be reponsible for monitoring compliance.
There are no detail notes for this visit.
2. Resident 6 was admitted to the facility with hospice services in 11/2019.
Resident 6's MAR dated 11/01/22 through 11/27/22 was reviewed during survey. The MAR lacked medication specific parameters for the following medications:
* Methadone (for pain) 7.5mg BID, in the morning and at bed time and Morphine (for shortness of breath and pain) 20mg, give 0.5ml every 3 hours PRN lacked medication specific instructions as to when to administer the PRN Morphine in relation to the routine Methadone.
* An order for Lorazepam, 0.5mg, "give 1-2 tablets daily at bedtime for insomnia (If 1 tab is not effective may give 2 tabs the next night)", did not provide clear direction to staff as to how many tablets should be administered when used several nights in a row.
The need to ensure the MAR provided clear medication specific parameters was discussed with Staff 2 (Health and Wellness Director) on 11/30/22. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 3 and 6) whose medications and treatments were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.
A review of Resident 3's 11/01/22 through 11/28/22 MAR showed inaccuracies in the following areas:
* There was no reason for use listed for Vitamin B complex;
* Staff documented Vitamin D was "unavailable" "reordered" on 11/21/22, 11/26/22, and 11/27/22, but documented the medication had been administered on 11/22/22, 11/23/22, 11/24/22 and 11/25/22; and
* There were unclear parameters for PRN pain medications Acetaminophen, Naproxen and oxycodone, regarding which medication to give when and in what order.
The need to ensure the MARS were accurate, included the reason for use for all medications, and provided clear parameters for PRN medication was discussed with Staff 1 (General Manager), Staff 2 (Health and Wellness Director), and Staff 3 (Director of Regional Operations) on 11/28/22 and 11/29/22. They acknowledged the findings
OAR 411-054-0055 (2) Systems: Medication Administration
Residents 3 and 6 MARs have been reviewed, all medications have reason prescribed, reflects clear parameters regarding PRNs for a single problem, and range orders updated with clear direction, range removed.
Med techs and Caregivers have been re-trained to properly document in the MAR as to why medications or treatments were missed or refused. Med techs have been re-trained on proper documentation and protocol to obtain medication within 24 hours from order, if unable to obtain Health and Wellness Director to be notified. Missed medications and treatments will be reviewed daily during the clinical meeting by Health and Wellness Director and RN. Proper parameters have been updated and are resident specific, and provide instruction for staff. H&W Director will conduct a monthly audit of the medication administration system.
Health and Wellness Director will be reponsible for monitoring compliance.
2. Resident 9 was admitted to the facility in 01/2023 with diagnoses including cancer and hypertension.
Resident 9's 05/01/23 through 05/09/23 MAR was reviewed and identified the following:
a. Reason for use not documented for:
*Cardizem (calcium channel blocker);
*Magnesium (supplement);
*Mirtazapine (antidepressant); and
*Triamcinolone cream (corticosteroid).
b. Lacked clear parameters for use:
*Albuterol inhailer (COPD);
*Brimonidine (glaucoma);
*Dorzolamide-timolol (glaucoma); and
*Latanoprost (glaucoma).
On 05/10/23, the need to ensure MARs had reasons for use and clear parameters for unlicensed staff to follow was discussed with Staff 2 (Health and Wellness Director). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs included reason for use and provided resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 7 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 09/2019 with diagnoses including localized edema, restless leg syndrome and Parkinson's disease.
Resident 7's MARs from 05/01/23 through 05/09/23 and physician orders were reviewed, and revealed:
a. The following PRN medications lacked resident-specific parameters including sequential order of use:
* Bisacodyl 10mg suppository (for bowel care);
* Fleet glycerin adult suppository (for bowel care);
* Acetaminophen 500mg (for pain);
* Oxycodone 10mg/ml (for pain); and
* Oxycodone Immediate 5mg (for pain).
b. The MAR had a duplicate order for PRN Lorazepam 0.5mg, which was discontinued after sharing finding with Staff 2 (Health and Wellness Director) and Staff 31 (RN) .
The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 2 and Staff 31 on 05/11/23 at 1:05 pm. They acknowledged the findings. No further information was provided.
OAR 411-054-0055 (2) Systems: Medication Administration
Resident 7's Physician Orders reviewed with PCP proper parameters and sequential order of use have been updated are resident specific, and provide instruction for staff.
Resident 9's reason for use was reviewed by PCP and updated to reflect clear parameters for medications placed.
Physician order request forms have been updated to ensure PCP includes parameters, instructions, and sequence for PRN use and reason for use as necessary. Nursing will conduct a review of medication orders daily.
Health and Wellness Director and RN will be responsible for monitoring compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and obtained a physician or other legally recognized practitioner's written order of approval for self- administration of medications for 2 of 3 sampled residents (#s 1 and 4) whose family member self-administered medications. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 2022 with diagnoses including Parkinson's disease.
Resident 1's clinical records revealed s/he was not able to administer his/her medications.
During an interview on 11/28/22, Witness 1 (Family Member) who lived with the resident said s/he administered Resident 1's medications not facility staff.
There was no documented evidence the facility evaluated Resident 1's or Witness 1's ability to safely self-administer medications. There was no physician's written order of approval for Witness 1 to self-administer Resident 1's medications.
The lack of signed orders indicating a physician's approval for Resident 1's family member to self-administer his/her medications was reviewed with Staff 2 (Health and Wellness Director) on 11/29/22. She acknowledged the above findings.
2. Resident 4 was admitted to the facility in 08/2022 with diagnoses including history of fall with fracture.
Resident 4's clinical records revealed s/he was not able to administer his/her medications.
During an interview on 11/30/22, Resident 4 said his/her daughter administered medications for him/her, not the facility staff.
There was no documented evidence the facility evaluated Resident 4's or the family member to safely self-administer medications. There was no physician's written order of approval for Resident 4 or the family member to self-administer the resident's medications.
The lack of signed orders indicating a physician's approval for Resident 4's family member to self-administer the resident's medications was reviewed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/29/22. They acknowledged the findings.
OAR 411-054-0055 (5) Systems: Self-Administration of Meds
Current orders to reflect approval for family to provide administration of medication have been received for resident 1 & 4.
Self-Administration orders will be reviewed prior to initial and quarterly evaluations by H&W director. Health and Wellness Director, RN or General Manger will be responsible for making sure orders are received and present during quarterly audits to ensure compliance of self administratiin orders.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, included a thorough assessment by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, provided instruction to caregivers on the correct use of and precautions for the device and included the use of the device in the resident's service plan for 1 of 1 sampled resident (#4) who had side rails on their bed. Findings include, but are not limited to:
On 11/30/22, Resident 4's bed was observed to have two quarter length side rails. The bed was positioned against a wall, the side rail against the wall was in the up position and the other was observed in the down position.
During an interview on 11/30/22, Resident 4 stated, " I don't care for them."
There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, facility staff were given instruction on the correct use and precautions related to the use of the device and no documented evidence the service plan had identified the use of and precautions related to the device.
The lack of an RN, PT or OT assessment and instructions for the use of supportive devices with potentially restraining qualities was discussed with Staff 2 (Health and Wellness Director) and Staff 6 (Health and Wellness/LPN) on 11/30/22. They acknowledged the findings.
OAR 411-054-0060 Restraints and Supportive Devices
Resident 4's service plan was updated to reflect supportive devices use and precautions, assessment conducted by RN, and orders for supportive devices received. A community quarterly audit has been performed to ensure knowledge of all devices and completion of assessed devices. Health and Wellness director or designee will identify the use of restraints and supportive devices during the initial move-in, and quarterly, H&W Director will ensure the facility RN assesses, H&W Director will be responsible for quarterly audit to ensure compliance.
Based on observation, interview, and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed by an RN, PT or OT prior to use, documented less restrictive alternatives prior to use, provided instruction to caregivers on the correct use of the device and included the use of the device in the resident's service plan for 1 of 1 sampled resident (#10) who had side rails on their bed. This is a repeat citation. Findings include, but are not limited to:
On 05/09/23, Resident 10's bed was observed to have a quarter length side rail on the bed.
There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, facility staff were given instruction on the correct use and precautions related to the use of the device and no documented evidence the service plan had identified the use of and precautions related to the device.
The lack of an RN, PT or OT assessment and instructions for the use of supportive devices with potentially restraining qualities was discussed with Staff 2 (Health and Wellness Director) and Staff 31 (RN) on 05/10/23. They acknowledged the findings and Staff completed an assessment of the side rail on 05/10/23.
OAR 411-054-0060 Restraints and Supportive Devices
Resident 10's service plan was updated to reflect supportive devices use and precautions, an assessment conducted by RN, and orders for supportive devices received. A full community audit has been performed to ensure knowledge of all devices and completion of assessed devices. The health and Wellness director or designee will identify the use of restraints and supportive devices during the initial move-in and quarterly evaluation, H&W Director will ensure the facility RN assesses when placed, H&W Director and RN will be responsible for quarterly audits to ensure compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 sampled newly hired employees (#s 12, 13, 27 and 30) completed required pre-service orientation training prior to assuming their job duties, and 2 of 2 long-term staff (#s 28 and 29) completed infectious disease prevention training by 07/01/22. Findings include, but are not limited to:
Staff training records were reviewed with Staff 2 (Health and Wellness Director) on 11/29/22. The following were identified:
* Staff 12 (Resident Assistant I), Staff 13 (Resident Assistant I), Staff 27 (Resident Assistant 1), and Staff 30 (Restaurant Server), hired on 11/08/22, 11/08/22, 11/08/22, and 10/09/22, respectively, did not complete all required pre-service orientation topics prior to beginning job duties; and
* Staff 28 (Resident Assistant II) and Staff 29 (Cook), hired on 11/21/17 and 01/04/18, respectively, did not complete required infectious disease prevention training by 07/01/22.
The need to ensure documentation of completion of pre-service orientation and infectious disease training was completed timely was discussed with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/30/22. They acknowledged the findings.
OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts
Staff 12,13,27, 28, 29, and 30 have completed required pre-service and infectious disease training.
All staff will complete pre-service orientation using Relias at the time of new hire paperwork conducted by the Business Office Manager. Health and Wellness Director will be required to show compliance with the completion of pre-service training prior to permitting staff to shadow and conduct hands-on training for care. Health and Wellness Director and Designee will use the checklist to document staff competency within 30 days of hire. General Manager and Business Office Manager will provide additional oversight and review all new staff training records before adding to the schedule. Annual training will also be completed using Relias and Relias records will be audited quarterly by Health and Wellness Manager.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to verify and document that 4 of 4 newly hired direct-care staff (#s 14, 16, 18 and 20) demonstrated satisfactory performance in all assigned duties within 30 days of hire. Findings include, but are not limited to:
Staff training records reviewed on 11/29/22 with Staff 2 (Health and Wellness Director) revealed the following:
Staff 14 (Resident Assistant I), Staff 16 (Resident Assistant I), Staff 18 (Resident Assistant II), and Staff 20 (Resident Assistant I), hired on 04/19/22, 01/10/22, 05/03/22, and 07/05/22, respectively, lacked evidence of completing the required training or demonstrating competency in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* Other duties as applicable.
The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/30/22. They acknowledged the findings.
OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff
Staff 14,16,18, and 20 have been properly trained and observed by Director, competency checklists have been completed and signed by Health and Wellness Director, and General Manager. Competency review and training documentation will be completed by Health and Wellness Director and General Manager within 30-days of a new hire. Business Office Manager and General Manager will provide oversight and review records monthly to ensure records are up to date, kept in employee files and in compliance.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 3 of 4 long-term direct care staff (#s 19, 21 and 23) completed the minimum required 12 hours of annual in-service training in all required topics. Findings include, but are not limited to:
Staff training records reviewed with Staff 2 (Health and Wellness Director) on 11/29/22 revealed the following:
Staff 19 (Resident Assistant II), Staff 21 (Resident Assistant II), and Staff 23 (Resident Assistant II), hired on 05/15/18, 05/29/20, and 05/15/14, respectively, lacked documented evidence of completing the required 12 hours of annual in-service training, including six hours related to dementia care.
The need to ensure all required in-service training hours were completed annually was discussed with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/30/22. They acknowledged the findings.
OAR 411-054-0070 (6-7) Annual Training and Other Requirements
Staff 19,21, and 23 has completed the required in-service training for direct care staff on Relias.
Annual training will also be completed using Relias and Relias records will be audited quarterly by Health and Wellness Director and Business Office Manager.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to document all required components on fire drill records and to provide fire and life safety instruction to staff on alternating months from fire drills. Findings include, but are not limited to:
Six months of fire drill records dated 05/01/22 through 11/29/22 were reviewed on 11/29/22. The following deficiencies were identified:
a. There was no documented evidence the facility had provided fire and life safety instruction to staff on alternating months of the fire drills.
b. The fire drill record did not document:
* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed;
* Number of occupants evacuated; and
* Evidence alternate routes were used during fire drills.
The requirements for fire and life safety training for staff and providing and documenting fire drills were discussed with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/30/22. They acknowledged the findings.
OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and instruction
General Manager provided fire drill process and documentation education to Plant Operation Supervisor. Documentation format has been updated to reflect the escape route used, problems or comments related to residents who resisted or failed drill, evacuation time, number of occupants, and alternative routes used.
Plant Operation Supervisor will update and ensure all residents participation in relocation or evacuation and that details including escape route, education, and residents that participated or refused are recorded and will maintain documentation compliance with monthly drills rotating times of day, and shifts, General Manager will audit all fire drills post-drill quarterly to ensure documentation and detailed compliance.
The General Manager is responsible to see that the corrections are completed and monitored.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:
Refer to C260, C270, C280, C310 and C340.
Refer to POC for citations C340, C310, C280, C270 and C260.
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 260.
Please see POC for C260
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:
The facility was toured on 11/28/22. The following deficiencies were identified:
* Multiple areas of wood handrails on the 2nd and 3rd floors were splintered and had rough edges;
* The laminate baseboard on the dining room divider wall was peeling away from the wall;
* The dining room divider wall had paint scratches and dings;
* A portion of the activity room ceiling was stained and cracked;
* The activity room walls had paint scratches and dings;
* The 2nd floor spa bathroom had a section of the laminate peeling away from the wall;
* The east 2nd floor laundry room had a broken light fixture; and
* The west 2nd floor laundry room wall had dust build-up under the ceiling vent.
The above areas needing cleaning and repair were reviewed with Staff 1 (General Manager) and Staff 3 (Director of Regional Operations) on 11/30/22. They acknowledged the findings.
OAR 411-054-0300 (4) (d-i) General Building: Doors-Walls, Cleanable
Each cited item has been cleaned/corrected to correct the rule violation affecting all residents.
Operations Leader reviewed the community plant operations policy with General Manager and Plant Operations Supervisor related communtiy appearance and repairs to maintain a safe environment for residents, team members and visitors.
Staff have been trained to report problematic condition, community staff will complete a TELS Work Order to report and track the maintenance issue.
The General Manager will conduct periodic audits and must be notified of any serious situation to ensure prompt corrective action is taken in accordance with the significance of the situation.
The General Manager is responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.