The findings of the initial survey, conducted 02/26/24 through 02/29/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
cc:cubic centimeter
CG:caregiver
cm:centimeter
F:Fahrenheit
HH:Home Health
HS or hs:hour of sleep
LPN:Licensed Practical Nurse
MA:Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
O2 sats:oxygen saturation in the
blood
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
RN:Registered Nurse
SP:service plan
TAR:Treatment Administration
Record
tid:three times a day
The findings of the first revisit to the re-licensure survey of 02/29/24, conducted 07/30/24 through 08/01/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second revisit to the initial survey of 02/29/24, conducted 11/25/24 through 11/27/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCCMemory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the third revisit to the re-licensure survey of 02/29/24, conducted 03/12/25 through 03/13/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 1 of 1 sampled residents (# 2) who received inaccurate fluid consistencies. Findings include, but are not limited to:
During acuity interview on 02/26/24, Resident 2 was identified as requiring modified texture meals and modified liquid consistencies. Modified diet textures were often made for prevention of choking or aspiration.
Resident 2's clinical records were reviewed. Resident 2 had a physician order, dated 01/04/24, for nectar thick consistency liquids. The MAR, dated 02/01/24 through 02/26/24 had instructions that included "All liquids given at meals including beverages and broth soups should be thickened to a nectar (or honey) consistency".
Resident 2's current service plan, dated 12/11/23, noted the resident had trouble swallowing and pocketed food. S/he required a pureed texture diet with nectar thick liquids.
During meal observations of Resident 2 and interviews with staff on 02/26/24, the following was noted:
* At 12:03 pm Resident 2 was observed to have a glass of water that was clear on the top half and cloudy on the bottom half. The resident also had a bottle of a nutritional drink with a straw.
* At 12:10 pm Staff 8 (MT) confirmed thickener had been added to the water glass. She relayed she did not add thickener to the water but "I did the [nutrition shake]." Asked how much thickener was added to the water and the shake. She confirmed, "One small scoop," and the glass used for the water was "maybe six ounces." She was unable to state how many ounces were in the shake and surveyor confirmed it was eight ounces. To prepare thickened liquids correctly, the caregivers had to know how many ounces of fluid needed to be thickened and the target consistency.
* At 12:34 pm the resident took sips of the water and no coughing was observed.
* At 12:50 pm Resident 2's family member arrived and requested a new glass of water for his/her parent. The surveyor observed Staff 21 (CG) put water in the glass and added one scoop of powder, stirred, and delivered the water to Resident 2. She confirmed she used one "small scoop" which was "half a teaspoon (tsp)." Staff 21 relayed the amount of thickening powder that was added to the glass depended on the size of the cup but she was not aware of how much thickener to add for Resident 2.
* At 2:04 pm Staff 22, (CG) was unclear how much thickener to use and if Resident 2 required nectar or honey thick fluid consistency.
* At 2:15 pm Staff 6 (MT) was not clear if adding the thickener was the responsibility for the MT's or caregivers and how much thickener to add, but the resident will "tell us [his/her] preference and if it's good or not."
*At 2:25 pm Staff 16 (MT) stated "Normally the MT does the thickener but I think we use two scoops with a "spoon".
*At 2:29 pm observation of the thickener bottle identified the following instructions for nectar thick fluid consistency for four fluid ounces:
a. Water - 3.5-4 tsp; and
b. Nutritional Supplement Drink - 4-4.5 tsp.
*At 2:30 pm an interview with Staff 8 confirmed both caregivers and MT's can provide the thickened fluid. The surveyor directed Staff 8 to the instructions on the bottle and she showed the surveyor the prescription label on the front of the thickener bottle that stated "Use as directed" and "this was the instruction we go by." Her process was to add two small scoops (1/2 teaspoon/scoop) for the nutrition shake "because the bigger scoops thickens it too much" and the resident is "unable to drink through the straw. With water, we give one small scoop."
*At 2:55 pm on 02/26/24 the surveyors shared the observations and interviews with Staff 2 (Health and Wellness Director/RN) and Staff 3 (Memory Care Administrator). Staff 2 acknowledged the instructions on the MAR were "confusing" and would clarify with hospice the proper consistency. Staff 3 reported the facility had been using the pre-thickened packets for Resident 2 and asked hospice to continue with the same product but they provided the powdered thickener instead. They acknowledged the staff should have received some training in using the powder to thicken liquids and implemented a plan to address staff competency during the survey.
On 02/27/24 at 12:13 pm an order was provided for Resident 2 to continue nectar thick liquids and the MAR was updated to reflect the clarified order.
The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 2 and Staff 3 on 02/29/24. They acknowledged the findings.
OAR 411-054-0025 (4) Reasonable Precautions
1) For resident #2 we requested and received clarifying orders from Hospice around which liquids needed to be thickened and what that consistency should be.
2) Memory Care staff have completed in-service training related to using liquid thickener. All new staff will receive this training as part of their pre-service training.
3) Memory Care Administrator (MCA) and RN will monitor adherance to prescribed modified thickness of liquids.
4) The GM and MCA will be 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 all resident incidents were promptly investigated to rule out abuse and/or neglect and reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out, and documented for 1 of 2 sampled residents (# 2). Findings include, but are not limited to:
Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
A review of the resident's record during the survey revealed the following:
In an incident report on 01/28/24, at 6:30 a.m. Resident 2 was found in the bathroom on his/her knees with both elbows on the walker and his/her "pants and depends were around [his/her] ankles. Walker was in the middle of the shower". Resident 2 was able to state that his/her walker moved forward as s/he was pulling up his/her pants. Resident 2 sustained a bruise to the left knee.
The incident report also indicated Resident 1 was found to be "sitting in [his/her] wheelchair" in Resident 2's bathroom. The report lacked clarification regarding the reason Resident 1 was in the bathroom at 6:30 am and if there had been any contact between the two residents prior to the fall.
The investigation, completed 02/11/24 by Staff 3 (Memory Care Administrator), lacked documented evidence the incident had been thoroughly investigated to determine if Resident 1 contributed to Resident 2's fall and to rule out abuse or neglect, or reported to the local SPD office.
Staff 3 stated in an interview on 02/29/24 the unwitnessed incident was not thoroughly investigated or reported to the local SPD office.
On 02/29/24, the incident was reported to SPD at the request of the surveyor.
The need to investigate resident incidents to rule out abuse and neglect and report to the local SPD office as required was discussed with Staff 3 on 02/29/24. She acknowledged the findings.
OAR 411-054-0028 (1-3) Abuse Reporting and Investigation
1) The incident was re-investigated and it was found to be an incident with resident #1 and a separate incident with resident #2, they just happened to occur in the same location. The staff who initially created incident report has been terminated as an employee.
2) All Memory Care staff have received in-service training on incident reporting. This training included documentation, communication and expections for reporting incidents involving more than one resident.
3) MCA has reviewed policies around what incidents are reportable to APS. MCA will review incident reports within 24 hours to rule out abuse or neglect and document in the investigation when it is ruled out. If unable to rule out, or if incident meets the standard for reporting according to state policy or company policy, MCA will immediately report to APS. Any incident that includes a sentinal event will be investigated and reported to APS immediately.
4) The GM and MCA are responsible to see that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and reported to the local SPD office if abuse could not reasonably be ruled out for 1 of 2 sampled residents (# 4). This is a repeat citation. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 01/2024 with diagnoses including vascular dementia.
The resident's service plan, dated 07/24/24, progress notes, dated 05/01/24 through 07/23/24, Resident Incident Reports and Care Plan notes, dated 05/10/24 through 07/18/24, were reviewed and staff were interviewed. The following incidents were identified:
* 05/18/24 - "Resident was very agitated and got a hold of chair where another resident was sitting and began screaming.";
* 05/21/24 - The resident "was sitting in [his/her] chair alone and [another resident] came up and [pushed the Resident 4's] chair." The resident screamed and [the other resident] slapped [Resident 4] with both hands against the ears."
There was no documented evidence the above mentioned incidents were immediately reported to the local SPD office and then investigated by the facility.
* 06/15/24 - "Bruise is still yellow on forehead and purple/red on eye. While brushing [his/her] hair found another yellow bruise on the left side of the head in [his/her] hair."; and
* 07/08/24 - "[Resident] was in room all day [s/he does] have a bump and [bruises] on [his/her] forehead and is yellow, not sure how that [bump happened]."
There was no documented evidence the above mentioned incidents were immediately investigated by the facility and reported to the local SPD office if abuse could not be reasonably ruled out.
On 08/01/24, the above four incidents were reported to SPD at the request of the surveyor.
The need to investigate resident incidents to rule out abuse and report to the local SPD office when abuse could not be ruled out was discussed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse), and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
OAR 411-054-0028 (1-3) Abuse Reporting and Investigation
1) All notes and incident reports for resident #4 have been reviewed and no further incidents requiring reporting to APS have been found. All notes and incident reports for resident #4, and all other residents, are reviewed daily to ensure all incidents are approriately documented and reported.
2) All Memory Care staff, including MCA (memory care administrator) have received a 1 hour training from an APS investigator about identifying incidents that require notification of emergency services, proper documentation of incidents, and incidents that should be reported to APS. The training given by APS investigator will be recorded. New staff will watch this training as part of their onboarding.
3) MCA, Memory Care LPN, or Memory Care coordinator will review all incident reports within 24 hours to rule out abuse or neglect and document in the investigation when it is ruled out. If unable to rule out, or if incident meets the standard for reporting according to state policy or company policy, MCA, LPN, or Coordinator will immediately report to APS. Any incident that includes a sentinal event will be investigated and reported to APS immediately.
4) The GM and MCA are 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 and preferences, provided clear direction regarding the delivery of services, and services were implemented for 1 of 2 sampled residents (# 2) whose service plans were reviewed. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
Observations of the resident, interviews with staff and review of the most recent service plan, dated 12/11/23, 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 being implemented in the following areas:
* Eating, including current diet texture and fluid consistency, level of assistance, and aspiration precautions;
* Level of assistance with personal hygiene and grooming;
* Level of assistance with mobility including ambulation and bed mobility;
* Shower coordination with hospice and facility;
* Use of arm protectors for skin integrity;
* Sleeping location including positioning with pillows;
* Use of side rails, including safety checks;
* Instructions for oxygen use including when to use, liter flow, cleaning and replacing supplies; and
* Evacuation status.
The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 2 (Health and Wellness Director/RN) and Staff 2 (Memory Care Administrator ) on 02/29/24. They acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General
1)Resident #2's service plan has been updated to reflect current care needs and clear directions for staff.
2) MCA will review all Memory Care resident care plans to ensure they accurately reflect current care needs, dietary needs and have clear directions for staff.
3) MCA will meet with RN weekly to discuss residents who need a change of condition assessment and their changing care needs.
4) GM and MCA are responsible to see that the corrections are completed/monitored.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction regarding the delivery of services, and services were implemented for 2 of 3 sampled residents (#s 3 and 4) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 06/2024 with diagnoses including major neurocognitive disorder.
Observations of the resident, interviews with staff, and review of the most recent service plan, dated 07/17/24, 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 being implemented in the following areas:
* Frequency of assistance needed to turn in bed;
* Ensuring non-slip socks were on when shoes were off;
* Independent with going to the dining room;
* Cognition status;
* Independent with nail care; and
* Current non-pharmaceutical interventions for pain.
The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse), and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
2. Resident 4 was admitted to the facility in 01/2024 with diagnoses including vascular dementia.
Interviews with staff and review of the most recent service plan, dated 07/24/24, 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:
* Frequency of safety checks;
* Safety concerns relating to why the resident's personal grooming and hygiene supplies were in a locked drawer in his/her bathroom;
* Specific directions on assisting the resident to the restroom in order to reduce behaviors; and
* Updated behavior interventions reflective to the resident's change of condition.
The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse), and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General
1) Resident #3 and #4's service plan has been updated to reflect current care needs and clear directions for staff.
2) MCA will review all Memory Care service plans to ensure they accurately reflect current care needs, safety concerns, behavior interventions, and clear directions for staff.
3) MCA will meet with LPN, RN, and care coordinator weekly to discuss residents who need updates to their service plans including change of condition assessments and their changing care needs.
4) GM and MCA are 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 preferences and provided clear direction regarding the delivery of services for 1 of 3 sampled residents (#8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 8 was admitted to the MCC in 03/2024 with diagnoses including dementia.
The resident's current service plan dated 10/19/24 was reviewed, observations were made, and interviews with the resident and caregivers were conducted between 11/25/24 and 11/27/24. Resident 8's service plan was not reflective and/or did not provide clear instruction to staff in the following areas:
* Adaptive equipment to use while ambulating in room versus throughout the community versus during evacuation;
* Physical restrictions secondary to placement of pacemaker;
* Home health services received, including name and number of the provider;
* Food preferences that do not include bread products;
* Grooming assistance needed when brushing hair;
* Toileting hygiene assistance required;
* Instructions when the resident refused to wear compression stockings;
* Stuffed animal used for emotional support;
* Preferences around the resident's door being open; and
* Blanket preferences.
The need to ensure service plans were reflective of the identified needs and preferences of the resident and provided clear direction to staff was discussed with Staff 3 (MCC Administrator), Staff 23 (RN) and Staff 22 (RCC) on 10/27/24 at 12:12 pm. They acknowledged the findings.
OAR 411-054-0036 (1-4) Service Plan: General
1) Resident #8's service plan has been updated to reflect current care needs, coordination of care with hospice and preferences.
2) Memory Care Administrator and Resident Care Coordinator will review all Memory Care service plans to ensure they accurately reflect current care needs, current preferences and clear directions for staff.
3) MCA will meet with RN, and care coordinator weekly to discuss residents who need updates to their service plans including change of condition assessments and their changing care needs.
4) GM and MCA are 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 evaluate changes of condition, determine and document interventions, and monitor each resident consistent with his or her evaluated needs until resolution, for 2 of 2 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including dementia, osteoporosis, and Type II Diabetes.
The resident's current service plan, dated 12/18/23, progress notes dated 08/27/23 through 02/26/24, and incident reports and investigations were reviewed, and staff were interviewed.
The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:
a. On 9/20/23 Resident 1 was found on the floor of her/his room and was sent to the emergency room for treatment. Resident 1 returned to the facility with a diagnosis of neck fracture and scalp laceration.
* Resident 1's ER discharge instruction included wearing a neck brace at all times, however, there was no record the service plan was updated with the intervention to wear the neck brace.
b. On 9/22/23 Resident 1 was found on the floor of his her/room with a new skin tear on his/her upper right forearm.
* There was no documentation the skin tear was monitored until resolution.
c. On 10/03/24 a caregiver documented Resident 1 was observed "both legs were damp and clear liquid was coming down legs". Resident 1's right leg was noted as swollen and the left leg had two scrapes draining clear liquid.
* The 10/03/24 progress noted stated "nurse was notified", however there was no documented evaluation of the weeping edema or skin, service plan update, or weekly monitoring until 10/24/24.
d. On 01/24/24 progress note indicated staff discovered a small cut on Resident 1's left hand.
* There was no documented evaluation or monitoring of the wound until resolution.
The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 2 and Staff 3 (Memory Care Administrator) on 02/29/24. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
The resident's current service plan, dated 12/11/23, progress notes, dated 08/27/23 through 02/26/24, and incident reports and investigations were reviewed, and staff were interviewed.
a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and documentation of resolution:
* 09/22/23 - Urinary tract infection;
* 01/28/23 - Fall with injury;
* Missed medications on: 09/26/23, 12/04/23, 12/09/23 and 12/11/23;
* New medications on: 09/25/23 and 12/03/23;
* Medication dosage change on: 09/20/23; and
* Medication given outside parameters on: 10/06/23.
b. The following short-term changes of condition lacked documentation that actions or interventions were determined, documented, and communicated to staff on each shift:
* 11/07/23 - Fall with injury;
* 12/20/23 - Fall with injury; and
* 02/03/24 - Fall with injury.
c. The resident was identified as a fall risk on the service plan and progress notes indicated that s/he experienced four falls between 11/07/23 and 02/03/24. There was no documented evidence that current fall interventions were consistently monitored for effectiveness.
The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, fall interventions were monitored for effectiveness, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 2 and Staff 3 (Memory Care Administrator) on 02/29/24. They acknowledged the findings.
OAR 411-054-0040 (1-2) Change of
Condition and Monitoring
1) For residents #1 and 2, interventions were established for change of condition assessments and monitoring and will continue to be monitored and documented by facility RN.
2) Memory Care Staff have completed training related to monitoring and documenting resident changes of condition. Reportable conditions will generate incident reports and Temporary Service plans that will be reviewed by the MCA/RN. Temporary service plans will include instruction for staff on what to monitor and facility designee/RN will document resolution of incident. Staff will ensure that the RN is notified of any changes in residents needs, RN will complete Change in Condition assessments, monitoring and service plans are updated as needed.
3) The GM and MCA or Designee will review incident reports and significant changes of condition within 24 hours. Short Term monitoring Plans will be reviewed weekly to ensure continued compliance.
4) The GM and MCA are responsible to see that the corrections are completed/monitored.
Based on interview and record review, it was determined the facility failed to evaluate changes of condition, determine and document interventions, and monitor each resident consistent with his or her evaluated needs until resolution, for 1 of 3 sampled residents (# 4) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 01/2024 with diagnoses including vascular dementia.
The resident's service plan, dated 07/24/24, progress notes, dated 05/01/24 through 07/23/24, Resident Incident Reports and Care Plan notes, dated 05/10/24 through 07/18/24, were reviewed, and staff were interviewed.
The following short-term changes of condition lacked documented evidence of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly, and/or documentation of resolution:
* 05/11/24 - "Resident complained of pain on [his/her] fingers and left elbow. No medications for pain";
* 05/18/24 - Resident 4 took a chair where another resident was sitting and screamed at the other resident;
* 05/21/24 - The resident was hit by another resident;
* 06/08/24 - Injury of unknown cause relating to bruising of right side of forehead;
* 06/15/24 - Injury of unknown cause relating to bruising on left side of head in his/her hair; and
* 07/08/24 - Injury of unknown cause relating to a bump and new bruise on the resident's forehead.
The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored with weekly progress noted through resolution was discussed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse), and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
OAR 411-054-0040 (1-2) Change of
Condition and Monitoring
1) Resident #4's notes and incident reports have been reviewed to ensure all temporary changes in condition are being documented appropriately and monitored.
2) Memory Care staff have received training related to monitoring and reporting temporary changes in condition. This training includes how to create TSPs (temporary service plans), what changes (including pain, skin, wounds, falls, medication changes, and complaints) require incident reporting, monitoring, notification of the RN.
3) The GM and MCA or Designee will review incident reports and significant changes of condition within 24 hours. Short Term monitoring Plans will be reviewed weekly to ensure continued compliance. MCA, or designee will ensure that all TSPs include instructions for staff on what to monitor and document on and MCA, RN, LPN, or designee will document resolution of incident. RN will ensure there are completed change assessments, monitoring and service plans are updated as needed.
4) The GM and MCA are responsible to see that the corrections are completed/monitored.
2. Resident 6 was admitted to the MCC in 08/2024 with diagnoses including heart disease and dementia.
Observations of the resident and interviews with staff were completed. The resident's service plan, dated 08/30/24, and progress notes dated 09/14/24 through 11/25/24 were reviewed. The following was revealed:
a. Resident 6 was evaluated at admission and noted to have intact skin. A progress note dated 10/02/24 documented discovery of a "wound on top of middle toe on right foot with redness and pain and swelling."
Resident 6 was placed on alert charting; however, the alert charting comments dated 10/04/24 noted an intervention, "recommended to not wear any sock and if possible, to use slipper." This intervention was documented in the alert charting and monitoring book for med techs, it was not available to direct care staff, and the service plan was not updated.
b. A 10/04/24 Med Tech note documented "appears to have a stage II pressure injury." There was no documented evidence the facility evaluated the wound and referred Resident 6 to the facility RN for assessment.
In interview on 11/26/24 Witness 1 (Home Health RN) stated they had taken over Resident 6's wound care from another Home Health RN on 10/14/24. Witness 1 stated the wound was 1 x 1.5 cm and was improving, and that he communicated with the facility through notes.
c. On 10/24/24, Resident 6 was prescribed the new medication cephalexin 500mg (antibiotic) every six hours from 10/24/24 through 11/03/24. There was no documented evidence Resident 6 was monitored for side effects related to the medication.
The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff on each shift, and referred significant changes of condition to the facility nurse was discussed with Staff 3 (MCC Administrator), Staff 24 (LPN), Staff 22 (RCC) and Staff 23 (RN) on 11/27/24. They acknowledged the findings.
3. Resident 7 was admitted to the facility in 05/2024 with diagnoses including Lewy body dementia.
The resident's 10/01/24 through 11/25/24 MAR and 09/24/24 through 11/26/24 progress notes were reviewed and revealed the resident experienced the following medication changes in the review period:
* 10/04/24 - New medication order, start escitalopram (for depression) 2.5 mg by mouth every day for ten days; and
* 10/11/24 through 10/15/24 - Missed doses, pantoprazole (for gastroesophageal reflux disease) 40 mg twice daily.
The facility lacked documented evidence the medication changes had interventions or actions developed and communicated to staff on each shift and the changes were monitored with progress noted at least weekly through resolution.
The need to ensure short-term changes of condition had interventions or actions developed and communicated to staff on each shift and documentation to reflect monitoring at least weekly through resolution was discussed with Staff 24 (LPN) on 11/26/24 and with Staff 3 (MCC Administrator), Staff 22 (RCC) and Staff 23 (RN) on 11/27/24. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to refer significant changes of condition to the facility nurse, to determine and document what actions or interventions were needed for short-term changes of condition, to communicate resident-specific instructions and interventions to staff on each shift, and to monitor the change of condition, at least weekly, until resolved for 3 of 3 sampled residents (#s 6, 7 and 8) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the MCC in 03/2024 with diagnoses including dementia.
The current service plan dated 10/19/24, temporary care plans dated 09/14/24 through 11/24/24, and progress notes dated 09/14/24 through 11/24/24 were reviewed. Interviews with staff were completed between 11/25/24 and 11/27/24.
The facility failed to determine action or intervention needed for the resident, communicate the action or intervention to staff on each shift, and/or document weekly progress until the condition resolved for the following conditions:
* 09/20/24 - B12 injection;
* 09/20/24 - Flu, shingles, pneumonia, and COVID vaccines received;
* 09/22/24 - Medication error with cephalexin (an antibiotic);
* 11/07/24 - Pacemaker placed;
* 11/07/24 - Incision and bruising from pacemaker placement;
* 11/10/24 - Melatonin (for sleep) and cephalexin (an antibiotic) not available; and
* 11/12/24 - Non-injury fall.
The need to ensure the facility determined and documented what action or interventions were needed for changes of condition, communicated the actions or interventions to staff on all shifts, and monitored the short-term changes of condition at least weekly through resolution was discussed with Staff 3 (MCC Administrator), Staff 23 (RN) and Staff 22 (RCC) on 10/27/24 at 12:12 pm. They acknowledged the findings, and no additional information was provided.
OAR 411-054-0040 (1-2) Change of
Condition and Monitoring
1) Resident #6, #7 and #8's notes and incident reports have been reviewed to ensure all temporary changes in condition are being documented appropriately and monitored. Staff instructions and interventions have been documented in each of their temporary service plans.
2) Shift change checklist which includes changes in condition that were observed as well as the items to monitor or interventions put in place related to these changes is initialled by each staff during shift change has been added. This checklist also includes notifying RN if any of these changes are significant. Reference sheets have been added to staff areas that describe what qualifies as a change of condition versus a significant change of condition. RN, MCA, and coordinator will attend shift change at least once per week to ensure this checklist is being followed and communication on changes in condition are being discussed. RN will conduct training with all memory care staff on updated system, change of condition monitoring, and notifying her of significant changes in condition.
3) Short Term monitoring Plans will be reviewed weekly to ensure continued compliance, including RN documentation. MCA, or designee will ensure daily that all TSPs include instructions for staff on interventions and documentation. MCA, RN, or designee will document resolution of TSPs.
4) The GM and MCA are responsible to see that the corrections are completed/monitored.
There are no detail notes for this visit.
2. Resident 6 was admitted to the MCC in 08/2024 with diagnoses including heart disease and dementia.
Observations of the resident and interviews with staff were completed. The resident's service plan, dated 08/30/24, and progress notes, dated 09/14/24 through 11/25/24 were reviewed. The following was revealed:
Resident 6 was evaluated at admission and noted to have intact skin. On 10/02/24, a progress note documented the discovery of a "wound on top of middle toe on right foot with redness and pain and swelling."
The 10/02/24 TSP noted "open wound and swelling redness in middle toe on right foot, monitor for continued worsening of symptoms or any other concerns."
On 10/04/24, a Med Tech note documented "provided wound care to second toe on right foot. [S/he] appears to have a stage 2 pressure injury."
On 11/26/24, Witness 1 (Home Health RN), stated the wound was currently 1 x 1.5 cm and improving.
The development of a Stage II pressure ulcer constituted a significant change of condition requiring an assessment by the facility RN including findings, resident status, and interventions made as a result of this assessment. There was no documented evidence the facility RN completed an assessment of Resident 6's wound until requested by the survey team on 11/26/24.
The requirement for an RN to complete a timely assessment of significant changes of condition was discussed with Staff 3 (MCC Administrator), Staff 24 (LPN), Staff 22 (RCC) and Staff 23 (RN) on 11/27/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessed significant changes of condition timely, documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 6 and 7) reviewed for significant changes of condition. Findings include, but are not limited to:
1. Resident 7 was admitted in 05/2024 with diagnoses including Lewy body dementia.
The 08/24/24 service plan noted Resident 7 required one-person to assist with toileting and independent or up to one person to assist with transfers and utilized a four-wheeled walker to ambulate independently.
Observations and interviews made during the survey indicated the resident experienced a decline in ADLs which resulted in a change from one-person assist for toileting and transfers to the need for two-person assist. Additionally, the resident demonstrated a decline in mobility from independent with ambulation to the need for a wheelchair with caregiver escort.
Review of progress notes and comments from the electronic care plan revealed the following:
* 11/13/24 " ...mobility is less, came out with wheelchair.";
* 11/14/24 " Resident seems weak and more slow in [his/her] mobility, [s/he] has been using the wheelchair the past few days.";
* 11/18/24 " ...resident is showing weakness in legs as transfers are getting much more complicated as resident is not holding [himself/herself] up as usual."; and
* 11/22/24 "[Resident 7] needed a lot of assistance ambulating and transferring."
In an 11/27/24 interview, Staff 23 (RN) stated she was made aware of Resident 7's decline and change of condition on 11/22/24, nine days after the resident began to require an increase in staff assistance with transfers and toileting and the use of a wheelchair with caregiver escort.
The facility lacked documented evidence an RN conducted a timely assessment of Resident 7's significant change of condition which included documentation of findings, resident status, and interventions made as a result of the assessment.
On 11/27/24 an RN assessment dated 11/26/24 was presented to the survey team.
The need for an RN to conduct an assessment timely when a resident experienced a significant change of condition was reviewed with Staff 3 (MCC Administrator), Staff 22 (RCC) and Staff 23 (RN) on 11/27/24. They acknowledged the findings.
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services
1) Resident #6 and #7 have been assessed by community RN for their significant changes in condition. Service plans have been updated to reflect current care needs.
2) Staff have completed additional training on incident reports including starting alert charting for significant changes of condition. MCA will create calendar updates in outlook for RN and MCA for 24 hours after significant change occurred to remind RN to complete assessment if not already completed.
3) Community RN to meet regularly throughout the week with MCA to discuss any significant changes in condtion. RN, MCA, and care coordinators meet weekly to discuss clinical updates (including falls, skin monitoring needs, significant changes in condition, and residents on alert) Additionally community RN will work in memory care 16 hours per week and be available on call for staff outside of those hours.
4) GM and MCA are responsible to see that the corrections are completed and monitored
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 2 sampled residents (# 2) during ADL care and meal service. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
During interviews and observations from 02/26/24 through 02/29/24, Resident 2 was noted to require one person assist for toileting and dressing.
a. During an ADL observation on 02/26/24 at 2:15 pm the following was noted:
* One caregiver assisted the resident walk into his/her bathroom with a walker. The resident sat down onto the raised toilet seat prior to doffing pants while the caregiver looked for gloves. Resident was asked to stand up again and the resident and caregiver participated in doffing his/her pants and briefs, then resident sat down on the toilet.
* A second staff brought in gloves for the caregiver, she donned them and no hand hygiene was observed prior to the caregiver donning the gloves.
* Resident stood up from the toilet with verbal cues, held onto his/her walker while staff wiped his/her peri area with wipes. Staff pulled up the briefs, pants, adjusted the shirt and sweater, turned on the faucet to help wash the resident's hands, and adjusted his/her hand protectors all with the same soiled gloves.
* The staff member removed the soiled gloves, finished assisting the resident wash his/her hands, and then performed hand hygiene after leaving the resident's room.
b. During the survey, multiple meal observations on 02/26/24 through 02/29/24 were made of direct care staff providing meal service to residents. The following was noted:
* Staff were observed setting tables, serving meals, pouring beverages and assisting two residents eat/drink without wearing aprons or other barriers to prevent contamination between clothing and food;
* Multiple staff were observed delivering beverages and meals from the meal preparation area to the residents seated in the dining room. On multiple occasions the staff gathered the dirty plates, cups, and silverware, returned them to the preparation area and then continued to serve other residents' beverages and meals without performing proper hand hygiene between clean and dirty tasks;
* One staff assisted an unsampled resident sip his/her drink holding the cup and straw to the resident's mouth. Following this assistance, the staff served drinks to another table with no hand hygiene between tasks;
* One staff sat down next to Resident 2, stirred his/her soup with the resident's spoon without hand hygiene prior to assisting the resident;
* One staff doffed her gloves, handed the dirty gloves to another staff, opened a condiment packet and squirted onto a resident's plate. No observation of hand hygiene prior to assisting the resident;
* One staff cleared a coffee mug, plates and placemats off several tables, returned them to the serving counter, then assisted an unsampled resident with his/her drink. The staff held his/her cup and straw and no hand washing was observed between dirty and clean tasks.
* One staff moved dirty plates onto a tray and then with the same soiled hands grabbed a clean mug to serve a resident a drink;
* One staff assisted an unsampled resident with his/her drink and moved the bowl closer to the resident. Next, she moved to another table to assist Resident 2 with his/her soup, and immediately returned to the unsampled resident asking "Do you want more juice" and held the resident's cup and straw while assisting the resident take a sip. No hand washing was observed between assisting the two residents; and
*Meals delivered to resident apartments were not covered to prevent contamination during delivery.
Maintaining effective infection prevention and control while providing meal service, food delivery and ADL care was reviewed with Staff 2 (Health and Wellness Director/RN) and Staff 3 (Memory Care Administrator) on 02/29/24. They acknowledged the findings.
OAR 411-054-0050 (1-5) infection prevention and control.
1) Memory Care staff have completed in-service training around infection control in the dining room. This training included policies around hand washing, handling dirty items, assisting residents with eating, and wearing proper PPE. Infection control procedures while toileting residents have been reviewed with staff.
2)MCA and Memory Care Coordinator will monitor a meal service and toileting weekly to ensure staff are following infection control protocols.
3) The GM and MCA will be responsible to see that the corrections are completed and monitored.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for meal service, delivery of meals and medication pass. This is a repeat citation. Findings include, but are not limited to:
Observations of the lunch meal service was completed between 07/31/24 and 08/01/24 and revealed the following:
* Multiple care staff were observed serving meals and beverages, retrieving items in the MCC's kitchenette, touching residents, wearing the same pair of gloves without doffing the gloves or doffing gloves without performing hand hygiene before donning new gloves and not performing proper hand hygiene prior to or between meal tasks.
* A MT was observed to administer medications during the lunch meal. The MT was observed touching residents while administering the medications and then moving on to the next resident without performing hand hygiene; and
* Meals delivered to resident apartments were not covered to prevent contamination during delivery.
The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene during the meal service, food delivery, and medication pass was reviewed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse) and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
OAR 411-054-0050 (1-5) infection prevention and control.
1) Staff 1, 3, 24 and 26 acknowledged the need to ensure universal precautions related to the observations in the Statement of Deficiencies.
2)Memory Care staff have completed additional in-service training around infection control in the dining room. This training included going over policies around washing hands, handling dirty items, touching residents while helping with meals, and wearing PPE appropriately. Memory Care med techs have received training on infection control procedures while passing medications to different residents.
3)MCA, LPN, and Memory Care coordinator will monitor a meal service and med pass weekly to ensure staff are following infection control protocols.
4) The GM and MCA will be responsible to ensure 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 an accurate MAR was kept, including instructions for medications for 1 of 2 sampled residents (#2) whose records were reviewed. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
The resident's clinical record including MAR's, dated 02/01/24 through 02/26/24, and signed prescriber orders, dated 01/04/24, were reviewed.
a. The MAR lacked complete instructions for the following medications:
* PRN acetaminophen suppository;
* PRN bisacodyl suppository;
* PRN lorazepam; and
* PRN morphine sulfate.
b. Resident 2 had a physician order for nectar thickened fluid. The MAR's instructions added "All liquids given at meals including beverages and broth soups should be thickened to a nectar (or honey) consistency".
On 02/26/24 clarification of the fluid consistency was requested and an order to continue nectar thick liquids was received on 02/27/24.
The need to ensure accurate MARs were kept and included instructions for treatments and PRN medications was discussed with Staff 2 (Health and Wellness Director/RN) and Staff 3 (Memory Care Administrator) on 02/29/24. They acknowledged the findings.
OAR 411-054-0055 (2) Systems:
Medication Administration
1) Resident #2 orders are current to include appropriate administrations times, instruction, and peramiters.
2) The community will follow the medication service program for residents per policy. This will include accurate MAR, including reason for use on all medications. Necessary medication parameters and specific instructions will be entered by MCA/RN in EMAR upon receiving orders.
3) All medication orders received will go through a 3 check system to ensure accuracy of EMAR to reflect orders, third and final check will be reviewed and completed by the RN.
4) The GM, MCA and RN will be responsible to see that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept, including instructions for medications for 1 of 3 sampled residents (# 3) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 06/2024 with diagnoses including major neurocognitive disorder and heart failure.
The resident's 07/01/24 through 07/30/24 MAR was reviewed and revealed the following inaccuracies:
a. Resident 3 had an entry on the MAR directing staff to weigh him/her daily. The resident was not weighed daily per instructions for 19 out of 30 days reviewed.
b. There was no documented evidence if the resident was administered the 5:00 pm dose of acetaminophen (for pain) or the 6:00 pm dose of carvedilol (for hypertension) on 07/25/24. It was verified the resident received the above mentioned medications as the bubble packs were observed and there were no pills in either package for 07/25/24.
c. There was an order to administer "1 to 2" tablets of Senna, twice daily as needed for constipation. There was no documented evidence of clear direction to unlicensed staff for which amount to administer and after how many days of the resident not having a bowel movement.
The need to ensure accurate MARs were kept and included instructions for treatments and PRN medications was discussed with Staff 1 (Director of Operations), Staff 3 (Memory Care Administrator), Staff 23 (RCC), Staff 24 (Health and Wellness Nurse), and Staff 26 (General Manager) on 08/01/24. They acknowledged the findings.
OAR 411-054-0055 (2) Systems:
Medication Administration
1) Resident #3 orders are current to include discontinuation of daily weight checks as they are no longer needed, all medication administration is documented appropriately, orders have been clarified with doctor to include clear instructions and parameters.
2) The community will follow the medication service program for residents per policy. This will include accurate MAR, including reason for use on all medications. Necessary medication parameters and specific instructions will be entered in EMAR upon receiving orders. All medication orders received will go through a 3 check system to ensure accuracy of EMAR to reflect orders, third and final check will be reviewed and completed by the RN.
3) MCA, LPN, or Memory Care Coordinator will monitor adminstration records daily to ensure all documenation is accurate.
4) The GM, MCA and RN will be 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 a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use, and precautions of the device for 1 of 1 sampled resident (# 2) with two half-length side rails. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and pulmonary hypertension.
On 02/26/24 at 2:15 pm, Resident 2's bed was observed with two half-length side rails in the up position that were secured to the bed.
During an interview on 02/26/24, Resident 2 stated s/he used the side rails to help with positioning and safety when in bed.
On 02/27/24 a side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.
On 02/28/24 the RN completed a siderail assessment, a quarterly evaluation and an updated service plan that included instruction to caregivers on correct use and precautions.
The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 2 (Health and Wellness Director/RN) and Staff 3 (Memory Care Administrator) on 02/29/24. They acknowledged the findings.
OAR 411-054-0060 Restraints and
Supportive Devices
1) Updated bed rail assessments have been completed by facility RN for residents #2 and service plans have been updated to include the use of bed rails.
2) MCA and RN retrained on restraints and supportive devices assessment policy. Prior to the addition devices for any resident, an assessment will be completed by the facility RN or by the third-party PT/OT.
3) Reccomendations will be sent to the RN when a resident may require a transfer aide or supportive device. Transfer aids assessment will be reviewed quarterly as part of a 90-day evaluation or significant change of condition assessment. Bed rail evaluations will be reviewed on an ongoing basis or as needed with significant COC or quarterly evaluations.
4) The MCA, RN and GM are responsible for seeing that these corrections are being completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that addressed all the following activities of daily living (ADLs) for each resident and the amount of staff time needed to provide care. Findings include, but are not limited to:
The facility's ABST was reviewed on 02/28/24 at 12:15 pm with Staff 1 (General Manager) and Staff 3 (Memory Care Administrator) and found to be deficient in the following areas:
* Staff could not confirm all 22 required ADLs contributed to the generated minutes used to create a staffing plan;
* ABST data was reviewed for Residents 1 and 2 and the data included only 18 of the required 22 ADLs;
* Resident 1 had zero minutes added for laundry and housekeeping, non-pharmacy behavior interventions and fall risk interventions; and
* Resident 2 had zero minutes added for ambulation including escorting to dining and activities, repositioning in bed, and did not account for treatments including oxygen and thickener for his/her nectar thick fluid consistency needs.
On 02/28/24 at 3:35 pm, Staff 3 confirmed the staffing plan was generated from the actual time it took the caregivers to perform each task for a resident rather than the projected minutes as required.
The need to have all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 2 (Health and Wellness Director/RN) and Staff 3 on 02/29/24. They acknowledged the findings.
OAR 411-054-0037 (1-8) Acuity-Based
Staffing Tool
1) Resident #1 and 2 service plans have been updated to reflect appropriate minutes per task and all 22 ADLs for each populating in ABST.
2) MCA has been retrained on use of Eldermark platform and service planning tool related to all services including PRN to ensure all 22 ADLs populate in the ABST.
3) MCA will review all service plans to ensure the evaluation tool includes all 22 required ADLs to populate.
4) The General Manager and MCA will review service plans/ABST tool weekly in 1:1 meetings.
5) The General Manager and MCA will be 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 have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing, and to maintain written documentation of all training's completed. Findings include, but are not limited to:
During a review of staff training records on 02/27/24 at 12:30 pm, Staff 3 (Memory Care Administrator) and Staff 12 (Business Office Manager) were unable to provide documented evidence the sampled newly hired staff had demonstrated competency in all duties they were assigned for 1 of 2 sampled staff. Staff 3 provided the checklist used to assess competencies but acknowledged they were not completed for 8 of 11 Medication Technicians currently working independently.
The need to maintain written documentation of training completed by each employee and to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 3 (Memory Care Administrator) on 02/29/24. She acknowledged the findings.
Refer to Z155.
OAR 411-054-0070 (2) Staffing Rqmt
and Training: Training Rqmts
1) All direct care staff have been properly trained with competency evaluated, observed by MCA or Facility Designee and documented in employee files.
2) All new hire direct care staff will complete this training prior to providing any services to residents and given a schedule to work independently on the floor.
3) MCA will track and audit all new hires for required documentation in first week, 30 days, and annual to ensure all staff are compliant with trainings and documentation. General Manager and MCA will provide oversight and audit records during weekly meeting to ensure records are up to date and kept in employee file.
4) The General Manager and MCA will 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 their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 231, C 260, C 270, C 295 and C 310.
OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2) The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3) The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
Based on observation, interview, and record review, it was determined the facility failed to ensure their initial 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 and C 270.
OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2) The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3) The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:
Observations from 02/26/24 to 02/28/24 revealed exit doors to the interior courtyards of the Opal memory care unit failed to have an alarm or other acceptable system to alert staff when residents entered and exited the courtyard.
On 02/27/24, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 3 (Memory Care Administrator), and on 02/28/24 was discussed with Staff 11 (Maintenance Director). They acknowledged the findings and stated door alarms would be installed.
OAR 411-054-0200 (11-13) Call Sys, Exit
Dr Alarm, Phones, TV, or Cable
1) Alarms have been installed on both interior courtyard doors. These alarms alert Memory Care care staff on tablets they carry throughout their shift when a door has been opened.
2) Memory Care staff are trained on responding to these alarms as part of their pre-service training.
3) The Plant Operations Supervisor will monitor alarms to ensure they are in proper, working condition.
4) The GM and MCA will be responsible for seeing that 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 follow administrative licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 160, C 231, C 295, C 361, C 365, and C 555.
OAR 411-057-0140(2) Administration
Compliance
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2)The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3)The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
Based on observation, interview, and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. This is a repeat citation. Findings include, but are not limited to:
Refer to C 231 and C 295.
OAR 411-057-0140(2) Administration
Compliance
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2)The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3)The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired staff (#s 5, 7, 9 and 10) had documentation of completed orientation, 4 of 4 sampled newly-hired direct care staff (#s 5, 7, 9 and 10) completed pre-service dementia training prior to performing any job duties, and 2 of 2 sampled newly hired direct care staff (#s 7 and 9) completed demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:
The facility's training records were reviewed on 02/27/24 and the following was identified:
a. There was no documented evidence Staff 5 (Opal Program Supervisor), Staff 7 (MT), Staff 9 (MT) and Staff 10 (CG), hired 06/26/23, 12/21/23, 10/23/23 and 01/23/24 respectively, completed the following pre-service orientation topics prior to beginning their job duties:
* Residents' rights and the values of community-based care;
* Abuse and reporting requirements; and
* Fire safety and emergency procedures.
Additionally, there was no documented evidence Staff 5, 7 and 9 completed the following pre-service orientation topics prior to beginning their job duties:
* Infectious disease prevention training.
b. There was no documented evidence Staff 5, 7, 9 and 10 completed pre-service dementia training courses in all required training topics prior to beginning their job duties.
c. There was no documented evidence Staff 7 and 9 demonstrated competency in medication administration within the first 30 days of hire. In an interview on 02/27/24 with Staff 3 (Memory Care Administrator), she acknowledged she did not have a consistent process for evaluating competency for medication administration prior to staff passing medications independently and currently lacked verified competency of the task for Staff 6, 7, 13, 15, 16, 17, 18, 19 and 20.
At 4:00 pm the survey team met with Staff 3 and explained the deficient practice of not having a verified competency for medication administration and voluntarily provided and implemented a plan to address staff competency during the survey.
The need to ensure newly hired direct care staff completed all pre-service training topics prior to beginning any job duties and demonstrated competency within 30 days of hire was discussed with Staff 2 (Health and Wellness Director/RN) and Staff 3 on 02/29/24. They acknowledged the findings.
OAR 411-057-0155(1-6) Staff Training
Requirements
1) All direct care staff have been properly trained with competency evaluated, observed by HWD/RN and documented in employee files.
2) All new hire direct care staff will complete this training prior to providing any services to residents and given a schedule to work independently on the floor.
3) MCA will track and audit all new hires for required documentation in first week, 30 days, and annual to ensure all staff are compliant with trainings and documentation. General Manager and MCA will provide oversight and audit records monthly to ensure records are up to date and kept in employee file.
4) The General Manager and MCA will 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 provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 260, C 270, C 310, and C 340.
OAR 411-057-0160(2b) Compliance with
Rules Health Care
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2) The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3) The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to: C 260, C 270, and C 310.
OAR 411-057-0160(2b) Compliance with
Rules Health Care
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2) The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3) The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 260, C 270, and C 280.
OAR 411-057-0160(2b) Compliance with
Rules Health Care
1) Actions to correct each violation have been enacted by the facility as evidenced in this POC.
2) The MCA responsible for overseeing the various systems related to the violations have received additional training on facility policies and procedures.
3) The systems will be monitored on an ongoing basis should a concern or violation be identified, and weekly as part of the community's 1:1 meetings between GM and MCA.
4)The General Manager is responsible for overseeing the facility's health services and administrative compliance.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 2 residents (#s 1 and 2) whose activity plans were reviewed. Findings include, but are not limited to:
Resident 1 and 2's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and the service plans individualized to reflect one or more of the the following required components:
* Residents' current preferences;
* Abilities and skills;
* Emotional/social needs and patterns;
* Physical abilities and limitations;
* Adaptations necessary for the resident to participate; and
* Identification of activities for behavioral interventions.
There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.
The need to evaluate and develop individualized activity plans, including all required components for each memory care resident was discussed with Staff 5 (Opal Program Supervisor) and Staff 3 (Memory Care Administrator) on 02/28/24, they acknowledged the findings.
OAR 411-057-0160(2d) Activities
1) Resident #1 and 2's charts have been updated with an assessment that identifies their ability to participate in different types of activities based on their cognitive state related to their dementia.
2) MCA and Memory Care Activities Supervisor will develop person centered plan for each resident based on current preferences, abilities, social/emotional needs, adaptations needed and activities that work as behavioral interventions.Each new resident moving in will be assessed using these same tools and a plan developed before move-in.
3) The plans will be updated according to each person's assessment schedule or when significant changes occur.
4) GM and MCA will see that the corrections are completed and monitored.
There are no detail notes for this visit.