The findings of the re-licensure survey conducted 07/11/22 through 07/13/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 07/13/22, conducted 07/25/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview, and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#3) received services in a manner that promoted dignity,and homelike environment, but are not limited to:

Resident 3 admitted to the facility in March 2020 had diagnoses including bilateral above the knee amputee.

On 07/12/22, Staff 8 (CG) reported caregivers need to clean Resident 3's commode and urinal after each use due to the lack of mobility and dexterity by Resident 3.

In interview on 07/12/22, dried feces were observed on Resident 3's commode. Resident 3 reported that often times his/her commode had dried feces on it from staff not completely cleaning and " feels some staff don't care". Resident 3 reported feeling disrespected when staff left his/her commode soiled.  

On 07/13/22, the need to ensure residents are receiving services in a manner that promoted dignity, and a homelike environment was discussed with Staff 1 (Administrator) and Staff 7 (Regional Director). They acknowledged the findings.

OAR 411-054-0027 (1) Resident Rights

and Protection

1.Resident #3's commode was immediately cleaned and sanitized per resident's request.

2. Staff will be trained on resident rights and dignity as related to use of commodes and urinals being kept cleaned and free of urine and feces. Training will also include meeting resident needs and expectations in a dignified manner by 8/8/22.

3. Staff will audit two random residents per week on cleanliness of equipment  and also discuss if expectations are being met in a dignified manner. Audit to be completed weekly for the next 8 weeks and reviewed monthly at QA meetings.  

4. ED or designee.  

Based on observation and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The annual kitchen inspection was conducted on 07/11/22 and revealed the following:

* Black substance above the stainless steel backsplash;

* Two severely dented cans;

* Black substance and food particles on the dish washer;

* Damaged door frames and walls creating an uncleanable surface;

* Floor molding peeling off of wall; and

* Microwave had dried food particles on all interior surfaces.

A tour of the kitchen was conducted on 07/11/22 with Staff 1 (Administrator), Staff 7 (Regional Director) and Staff 5 (Dietary Director). Staff 1 and Staff 5 acknowledged the areas of kitchen needing cleaning, and repair.

The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1, Staff 5, and Staff 7 on 07/11/22. They acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident

Services Meals, Food Sanitation Rule

1. The black substance above stainless steel backsplash was scraped clean and recaulked 7/13/2022. The two dented cans were removed and the black subastance and food particles on top of dish washer was cleaned 7/11/2022. Damaged door frames and walls will be repaired by 8/10/22. The floor molding peeling off of wall was repaired on 7/13/2022. The microwave was cleaned of dried food particles on 7/11/2022.

2.  A new cleaning checklist was implemented 8/2/22 to include a comprehensive cleaning schedule.Kitchen staff were in-serviced on the new cleaning schedule on 8/2/22.

3. A weekly review of the cleaning checklist will be completed by dietary director and ED as well as a weekly kitchen walkthrough inspection.

4. Dietary Director and ED/designee.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of the care needs of the resident, provided clear direction regarding the delivery of services to staff, or were updated quarterly for 2 of 5 sampled residents (#s 4 and 5), whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 02/2020 with diagnoses including Type II diabetes mellitus.

a. Resident 4 was observed during the survey to wear a brace on the right thigh. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 03/14/22 through 07/11/22, revealed Resident 4's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Toileting status including personal hygiene;

* Transfer status for bathing;

* Use of a brace; and

* Dressing status, lower part of body.

b. Resident 4's service plan was last updated on 03/14/22, therefore not updated quarterly as of 07/12/22.

On 07/13/22, the service plan was discussed with Staff 1 (Administrator), Staff 6 (Regional RN) and Staff 7 (Regional Director). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.

2. Resident 5 was admitted to the facility in 03/2013 with a physician's order to self administer all treatments and medications.

Review of Resident 5's most recent service plan dated 07/07/2022 revealed the following.

* Staff would administer medication; and

* Take weekly measurements and apply dressing changes to chronic wounds weekly.

In an interview with Staff 2 (RN) and Staff 3 (LPN) they confirmed Resident 5 was able to self medicate and treat his/her own chronic wounds.

The need to ensure service plans were reflective of the care needs of the resident, provided clear direction regarding the delivery of services to staff was discussed with Staff 1 (Administrator) Staff 2, Staff 3 and Staff 7 (Regional Director) on 07/12/22. They acknowledged the findings.

OAR 411-054-0036 Service Plan.

1) Resident #4 care plan will be updated to appropriately reflect care needs including toileting status, transferring status for bathing, use of brace and dressing status of lower body. This was completed on 7/22/2022. #5's care plan was updated on 7/12/22 to appropriately reflect self administration of medications and encouragment of wound care and education on importance of wound care.

2. In-service was completed by RNC to management team to include appropriate and timely updates/review to service plan to ensure it appropriately reflects residents needs.

3.Staff will audit two resident service plans per week to ensure that they accurately reflect resident care needs. Audit will be completed weekly for next 8 weeks and brought to QA meeting for review.

4. Director of Health Services/ED or designee.  

2. Resident 4 was admitted to the facility in 02/2020 with diagnoses including Type II diabetes mellitus.

Resident 4 was observed during the survey to wear a brace on the right thigh.

Resident 4's clinical records were reviewed during the survey and revealed the following:

* 04/18/22 - A new medication for ear pain; and

* 06/23/22 - Fall with hospital stay and received a diagnosis of right femur (thigh bone) fracture.

There was no documented evidence the resident's change of condition was monitored, at least weekly, through resolution.

On 07/13/22, the above information was shared with Staff 1 (Administrator), Staff 6 (Regional RN) and Staff 7 (Regional Director). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored, for 2 of 2 sampled residents who experienced short term changes of condition (#s 4 and 5). Findings include, but are not limited to:

Review of Resident 5's progress notes dated 04/20/22 through 07/11/22 revealed the following:

* On 04/20/22, Resident 5 reported to Staff 3 (LPN) two skin issues on his/her left ischium and one in the groin;

* On 05/15/22, S/he reported to Staff 3 his/her skin issues had significantly improved; and

* No other documentation was found after 05/15/22.

In an interview with Staff 2 (RN) and Staff 3 on 07/11/22, it was revealed Resident 5 refused to have Staff 2 or Staff 3 assess his/her skin issues.

There was no documented evidence the facility evaluated the skin issues, developed interventions or instructions to staff or monitored until resolution.

On 07/12/22, Staff 3 evaluated Resident 5's skin issues and noted no open wounds.

The need to ensure changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition monitored was discussed with Staff 1 (Administrator), Staff 2, Staff 3 and Staff 7 (Regional Director) on 07/12/22. They acknowledged the findings.

OAR 411-054-0040 change of condition and monitoring.

1. On 7/12/22 met with resident #5 and was able to assess and address wound with resident and findings were documented. On 7/12/22 weekly monitoring was initiated and service plan updated. COC ongoing.

Resident #4's change of condition assessment from 6/28/22 was updated and completed on 7/15/22 with current ADL needs. Resident was placed on monitoring and weekly change of condition initiated.   

2. The 24 hour process will be reviewed and retrained with staff on 8/8/22 to assure that communication from staff regarding visualized changes are being documented for further follow up. In-servicing on change of condition was completed by RNC with RN on 8/1/2022.    

3. A review will be completed M-F during morning meetings with use of 24 hour process to determine potential change of condition identification. If change of condition found, a new resident evaluation will be completed with ongoing weekly monitoring being completed until issue is resolved. This audit will be ongoing and reviewed monthly at QA.  

4. DHS/ED or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure a Registered Nurse assessed, documented findings and developed appropriate interventions for 1 of  3 sampled residents (# 4 ) who experienced a right femur fracture. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2020 with diagnoses including Type II diabetes mellitus.

During the acuity interview on 07/11/22, the resident was identified to experience an injury to the right thigh.

Resident 4 was observed during the survey to wear a brace on the right thigh.

Clinical records noted on 06/23/22, the resident was sent out to emergency department and received a diagnosis of right femur fracture; and returned to the facility with a brace to the right thigh.

Resident 4 experienced a significant change of condition. Facility RN assessed the resident's status on 07/11/22. The assessment did not address the resident's condition which included findings, a description of the resident status and interventions made as a result of the assessment.

07/13/22, the failure to complete a RN assessment timely at the time of the significant changes of condition and initiate interventions as a result of the assessment was shared with Staff 1 (Administrator), Staff 6 (Regional RN) and Staff 7 (Regional Director). They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F)

Resident Health Services sig change

1. On 7/15/22 resident #4's Resident Assessment from 6/28/22 was updated with current resident condition and ADL needs and weekly change of condition monitoring initiated and is ongoing.

2. The 24 hour process will be reviewed and retrained with staff on 8/8/22 to assure that communication from staff regarding visualized changes are being documented for further follow up. In-servicing on change of condition was completed by RNC with RN on 8/1/2022.    

3. A review will be completed M-F during morning meetings with use of 24 hour process to determine potential change of condition identification. If change of condition found, a new resident evaluation will be completed with ongoing weekly monitoring being completed until issue is resolved. This audit will be ongoing and reviewed monthly at QA.  

4. DHS/ED or designee.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 07/11/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Resident 4's MARs, reviewed from 07/01/22 through 07/11/22, revealed the following:

* The resident received Glargine (insulin to treat diabetes) 30 units in the morning and 20 unit in the evening; and

* The insulin had been given by Staff 12 (Activities) and Staff 21 (Activities Director) on multiple occasions.

Review of Resident 4's delegation documentation during the survey revealed the following:

a. Re-delegations for Staff 12 was completed on 10/06/21 and scheduled for re-evaluation in 180 days which was approximately 04/06/22. Re-evaluation of the Staff 12 was completed on 05/26/22, which was 50 days after it was planned.

b. Initial delegation for Staff 21 was completed on 02/22/22. Staff 21 was to be scheduled for re-evaluation in 60 days which was approximately 04/22/22. There was no documented evidence the facility RN re-evaluated Staff 21's skills and ability as of 07/12/22.

On 07/12/22, the need to ensure all staff who administered insulin injections were appropriately delegated and documented in accordance with OSBN Administrative Rules was discussed with Staff 1 (Administrator), Staff 6 (Regional RN) and Staff 7 (Regional Director). They acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN

Delegation and Teaching

1. Staff member #12 was re-evaluated and re-delegated on 5/26/22. Staff #21 was re-delegated on 7/12/22. A review of all delegations was completed on 7/13/22 to ensure all staff are up to date for re-delegation and education.

2. A delegation tracking tool was rolled out to RN by RNC on 7/13/22.

3.Delegations will be audited weekly by RN and ED and brought to QA monthly for review of system.

4. DHS/ED or designee.

3. Resident 4 was admitted to the facility in 02/2020 with diagnoses including Type II diabetes mellitus and bilateral lower extremity amputation.

Resident 4 was observed during the survey to use a power wheelchair with a seat belt for mobility.  During the observation, the resident was not observed to use the seat belt.

Review of the resident's clinical record revealed the following:

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails;

* No documented evidence that other less restrictive alternatives had been attempted prior to use; and

* There was no clear instruction to caregivers on the correct use and precautions related to use of the device.

On 07/13/22, the need to complete an assessment and the required components for the use of devices with potentially restraining qualities was discussed with Staff 1 (Administrator), Staff 6 (Regional RN) and Staff 7 (Regional Director), They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities were assessed thoroughly by an RN, PT or OT prior to use and were evaluated on a quarterly basis for 3 of 3 sampled residents (#s 1, 3, and 4) who had siderails on their bed. Findings include, but are not limited to:

1. Resident 3's bed was observed during the survey to have half-length siderails attached to his/her bed.

Review of the resident's clinical record revealed the following:

* No documented evidence of an evaluation completed by an RN, PT or OT for the use of the side rails;

* No documented evidence that other less restrictive alternatives had been attempted prior to use; and

* There was no clear instruction to caregivers on the correct use and precautions related to use of the device.

On 07/13/22, the need to evaluate the use of devices with potentially restraining qualities and all required components was discussed with Staff 1 (Administrator) and Staff 7 (Regional Director). They acknowledged the findings.

2. Resident 1 was observed during the survey to have half-length siderails attached to his/her bed.

Review of the resident's clinical record revealed a siderail evaluation was completed on 1/16/22 and on 07/11/22. The facility failed to evaluate Resident 1's side rails on a quarterly basis.

On 07/13/22, the need to ensure supportive devices with restraining qualities were assessed quarterly was discussed Staff 1 (Administrator) and Staff 7 (Regional Director). They acknowledged the findings.

OAR 411-054-0060 Restraints and

Supportive Devices

1. Resident #3-A side rail evaluation and assessment was completed on 7/12/2022. Side rails were added to the care plan with instructions to the staff for use and precautions.

Resident #1-An assistive device evaluation was completed for side rails 7/11/22.

Resident #4-On 7/13/2022, a seat belt and reclining wheelchair assessment on power wheelchair was completed. The assistive device was added to care plan with insturctions to the staff for use and precautions.

2. A room to room review of all devices and equipment for potential need for evaluations and assessment was completed on 7/17/2022. All evaluations and assessments were completed and added to care plans. Staff will be in-serviced on reporting of new assistive devices on 8/8/22. An assistive device audit tool was rolled out to RN on 7/22/22 by RNC.

3. A room to room review for any new devices will be done monthly and changes will be added to care plans and assessments completed.

This audit will be completed for the next 8 weeks and brought to QA.

4. DHS/ED or designee.   

Based on interview and record review, it was determined the facility failed to ensure documentation that 1 of 3 sampled newly-hired employees (# 10) completed pre-service orientation prior to assuming their job duties. Findings include, but are not limited to:

On 07/12/22, Staff training records were reviewed with Staff 1 (Administrator).

Staff 10 (CG) was hired on 03/19/22. Staff 10 did not complete the following pre-service training topics before providing care and services to residents independently:

* Infectious Disease Prevention as of 07/12/22.

The need to ensure all newly hired staff completed pre-service training was discussed with Staff 1, Staff 6 (Regional RN) and Staff 7 (Regional Director) on 07/13/22. They acknowledged the findings.

OAR 411-054-0070 staffing requirements and training.

1. Staff #10 identified to be missing the infectious disease prevention was notified and training was completed on 7/22/2022.

2. RDO reviewed new hire process with ED/BOM on 7/12/22. New hire process and onboarding document packets made and rolled out to team on 7/12/22. New hire employee training tracker was rolled out with ED/BOM on 7/13/22.

3.Newly hired staff training records will be audited weekly for completion by BOM prior to staff member working with residents.  

4. ED/Business office manager or designee.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired direct care staff (#s 17 and 20) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 1 (Administrator) on 07/12/22, identified Staff 17 (CG) and Staff 20 (CG) lacked documented evidence competency was demonstrated in the following required areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid and abdominal thrust training.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1, Staff 6 (Regional RN) and Staff 7 (Regional Director) on 07/13/22. They acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within

30 days: Direct Care Staff

1. Staff #17 and #20 30-day required training and competency checklists were completed on 7/16/2022.

2. RDO reviewed new hire process with ED/BOM on 7/12/22. New hire process and onboarding document packets made and rolled out to team on 7/12/22. New hire employee training tracker was rolled out with ED/BOM on 7/13/22.

3.Newly hired staff training records will be audited weekly for completion by BOM prior to staff member working with residents.  

4. ED/Business office manager or designee.