The findings of the re-licensure survey conducted 9/14/21 through 9/16/21 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 09/16/21, conducted 02/10/22 through 02/15/22, 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 second re-visit to the re-licensure survey of 09/16/21, conducted 08/29/22 through 09/06/22, 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.

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 third re-visit to the re-licensure survey of 09/16/21, conducted 04/04/23 through 04/06/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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 4th revisit to the re-licensure survey of 09/16/21, conducted 06/23/23 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 provide effective administrative oversight to ensure quality of care and services were rendered in the facility. Findings include, but are not limited to:

During the relicensure survey, conducted 9/14/21 through 9/16/21, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the severity and number of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility

Administration: Operation

Refer to C 231, C 240, C 252, C260, C270, C282, C290

Based on observation, interview, and record review, it was determined the facility failed to provide effective administrative oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:

During the re-visit survey, conducted 02/10/22 through 02/15/22, administrative oversight to ensure adequate resident care and services rendered in the facility were found to be ineffective based on the number of citations.

Refer to deficiencies in report.

Refer to C 231, C 240, C 252, C 260, C 270, C 282, C 300, C 303, C 305, C 310, C 372, C 422 and C 455

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation.  Findings include, but are not limited to:

During the second re-visit survey, conducted 08/29/22 through 09/06/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of repeat and new citations.

Refer to deficiencies in report.

ADMINISTRATIVE OVERSIGHT

refer to plan of corrections for c240, c260, c270,c280, c282, c300,c303, c305, c310, c372, c455

3. Resident 4 was admitted to the facility in March 2021.

On 5/4/21 staff documented on the facility progress note the resident "has been with the same underwear for 5 days..."

The 8/26/21 service plan indicated the resident was incontinent in both bowel and bladder management and used adult briefs at all times. The service plan also noted the facility would provide stand-by assistance for toileting.

On 9/15/21, an incident report was requested. On 9/15/21 at 3:00 pm, Staff 2 (Resident Care Manager) stated there was no incident report and confirmed there was no facility investigation completed to rule out neglect of care related to wearing the same clothing.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator) and Staff 2 during the survey. The staff acknowledged the findings.  

2. Resident 3 was admitted to the facility in October 2020.

Resident 3's service plan, dated 5/27/21, directed staff to do two hour safety checks.  A progress note indicated Resident 3 had a fall on 9/1/21 and was sent to the hospital. There was no documented evidence noting why the resident was sent out. The After Visit Summary, dated 9/1/21 had a new diagnosis of a pelvic fracture.  An incident report was requested on 9/14/21.

On 9/15/21 at 2:11 pm Staff 2 (Resident Care Manager) and Staff 3 (RN) confirmed there was no facility investigation completed to rule out abuse and neglect.

An interview with Staff 2 on 9/15/21 at approximately 2:30 pm revealed the resident had been increasingly confused and the facility had been trying to obtain a physician's order to get a urine analysis. The facility suspected the resident may have had a urinary tract infection.

During an interview with Resident 3 on 9/15/21 at 2:40 pm, the resident stated s/he broke his/her tailbone but didn't recall what happened.

The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. The staff acknowledged the findings.

Based on interview and record review it was determined the facility failed to ensure incidents and reports of suspected abuse were thoroughly investigated to rule about abuse for 3 of 5 sampled residents (#s 2, 3 and 4) whose records were reviewed. Findings include but are not limited to:

1. Resident 2 was admitted to the facility in July 2018 and was identified in the acuity interview to be at risk for falls.

The resident's service plan 5/11/21 included the following fall interventions:

* When the resident was awake be sure that s/he was wearing shoes; and

* One hour checks to be completed around the clock.

The resident's progress notes listed the following incidents:

* 6/21/21 the resident was found on the floor and later complained of pain to his/her head and;

* 8/3/21 the resident was found on the floor and later complained of soreness to his/her lower back.

The 6/21/21 and 8/3/21 Investigation Forms for the incidents included the following questions:

* Was proper footwear worn; and

* When did [facility staff] last check on the resident.

Both questions were answered as N/A [non applicable] for both incidents.

In an interview with Staff 3 (RN) on 9/15/21, she confirmed the incidents were not thoroughly investigated including determining if staff were following the fall interventions noted for Resident 2.

The facility lacked documented evidence the incidents were thoroughly investigated to rule out neglect of care as a contributor to the residents injuries.  

The need to ensure incidents were thoroughly investigated to rule out abuse was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0028 (1-3) Abuse

Reporting and Investigation

1. All staff to complete Oregon Care Partners training for Abuse prevention and investigation prior to October 29, 2021

2. Staff will be trained on abuse reporting and Clinical meetings will be implemented to review all incident reports and documentation for changes indicative of abuse or neglect.

3. meeting at least weekly to review all incidents and documentation of resident condition.

4. Administrator tor designee to monitor

Based on interview and record review it was determined the facility failed to ensure incidents were thoroughly investigated to rule out abuse or suspected abuse for 1 of 3 sampled residents (#9) who was reviewed for injuries of unknown cause and injury falls. This a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in January 2021. During the acuity interview on 02/10/22 the resident was identified as having falls with injuries.

Resident 9's service plan dated and 12/08/21 and interim service plans

noted the resident required one person assist with transfers, use of a gait belt and assistance with toileting.

Progress notes dated 01/14/22 through 02/10/22 listed the following injury of unknown cause and injury falls:

* 01/21/22 - return from emergency room due to a fall;

* 01/21/22 - staff documented the resident had a swollen right buttock;

* 01/22/22 - staff walking by room heard the resident say "help me please". Resident was laying face down on the floor. Resident was sent to the hospital for hitting his/her head during the fall; and

* 02/04/22 - injury fall while in the bathroom which resulted in back pain.

There was no documented evidence the facility completed an investigation to rule out abuse or neglect for the injury of unknown cause and three injury falls.

On 02/11/22 at 2:00 pm Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) confirmed there was no facility investigation completed to rule out abuse and neglect for the injury of unknown cause and the injury falls.

Surveyor requested the facility self report the incidents to the local SPD office. Verification of self reporting was received prior to survey exiting the building.

The need to ensure incidents were thoroughly investigated to rule out abuse was discussed with Staff 1, Staff 2 and Staff 15 on 02/11/22. They acknowledged the findings.

1. Resident #9 incidents reported to APS and investigation completed for all incidents. All current and newly hired staff to complete oregon care partners training for abuse prevention and investigation.

2. Training tracking system implemented.

3. Clinical meetings to occur at least twice weekly to review resident incidents and documentation of resident condition.

4. Administrator or designee to monitor.

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

During a tour of the kitchen on 9/14/21 at 12:28 pm, it was determined the following areas were in need of cleaning or repair:

* Left side of the convection oven had food spills on its surface;

* Bottom of both ovens, underneath the doors were sticky with black and brown substances;

* Drawer of the prep table, underneath the pan storage had debris along the bottom surface and a sticky substance along the perimeter of the drawer;

* Bottom shelf of the prep table beside the two sink counter had debris and a sticky substance on its surface;

* Black oscillating fan had a thick build up of dust covering the guard;

* Shelf above the silverware storage had spillage on it;

* Food steamer had a damaged power button and debris and spillage around its perimeter;

* Cabinets underneath the service table had spillage on the surfaces and debris on the shelves and;

* Wooden prep table had a black substance covering its surface and was not easily cleanable.

The areas needing cleaning and repair were discussed with Staff 1 (Administrator) and Staff 4 (Executive Chef) on 9/16/21. They acknowledged the findings.

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

Services Meals, Food Sanitation Rule

1. Kitchen will be commercially cleaned by an outside agency. A cleaning roster will be implemented. A walkthrough of the kitchen will be completed weekly for a month after outside agency cleans, and then monthly going forward.

2. This is a new system being implemented to avoid re-occurrence.

3. weekly for a month, then monthly afterward.

4. Administrator or designee to complete walk-throughs of kitchen at timing intervals mentioned above. Administrator or designee to review completed cleaning rosters.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

During a tour of the kitchen on 02/10/22 at 10:30 am with Staff 4 (Executive Chef), it was determined the following areas were in need of repair:

* Food steamer had a damaged power button and was in need of being replaced; and

* White cabinets underneath the service table had broken doors and multiple areas of white laminate surface removed with exposed wood underneath.

The areas needing repair were discussed with Staff 1 (Administrator) and Staff 4 on 02/10/22. They acknowledged the findings.

1. Kitchen has been approved for renovations

2. Kitchen equipment and food service space will be replaced to avoid re-occurrence.

3. Will evaluate monthly after renovations.

4. Administrator or designee to complete.

See attached approved plans to renovate kitchen

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. The kitchen was observed in an unsanitary condition which posed a situation that could threaten the health, safety, or welfare of residents. This is a repeat citation. Findings include, but are not limited to:

Observation of the kitchen on 08/29/22 at 2:00 pm identified the following areas of concern:

1. Main kitchen area:

* Flies and gnats were observed throughout the kitchen;

* Floors throughout the kitchen, including walk-in cooler and freezer, food prep areas, behind and underneath ovens and appliances, had an extensive build-up of black matter, grease, and food debris;

* Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sinks were covered in black matter, grease, and corrosion;

* Pipes beneath cupboards and behind ice machine were covered with a layer of dirt, dust, and lint;

* Walls and ceilings throughout the kitchen had multiple spills, smears, and food splatters;

* Garbage cans throughout the kitchen area were uncovered, food debris and spills stuck to the outside of containers;

* Doors, door frames, ceiling, and walls had food splatters, spills, and stains;

* Exterior of ovens were covered in grease, food spills, orange and black sticky build up;

* Interior of ovens had a buildup of burnt food debris, grease, and spills;

* Oven hoods had a buildup of grease and grime;

* Floor drains had a buildup of rotting gray matter;

* Interior and exterior of walk-in cooler and freezer, including shelving, had food debris, spills, splatters, chipped paint, and areas of rusting;

* Kitchen janitor closet walls and flooring showed water damage and mold. The mop sink had a dense buildup of black matter and debris. A cluster of gnats was noted flying in the closet, and the door was covered in dead gnats;

* An additional closet connected to the kitchen area needed to be deep cleaned, sanitized, and properly organized;

* Undated and unlabeled food items were noted in the reach-in and walk-in cooler and freezer;

* Rolling carts throughout the kitchen had loose food debris, dried liquid spills, and stuck food matter;

* Food boxes were stored on the walk-in and dry storage floors;

* Multiple kitchen staff were observed not sanitizing hands upon entering the kitchen, nor washed hands between tasks, and were not consistently wearing face masks properly; and

* Multiple kitchen staff lacked documented evidence of Oregon Food Handlers certification.

2. Dry food storage area:

* Extensive build-up of black matter/dirt/food debris was observed on the floor and behind/underneath shelving units;

* Cardboard box of rotting potatoes stored on shelving unit was infested with gnats;

* Clusters of flies were seen swarming around the back of the dry storage area and coming through the seams of the plywood ceiling;

* Ceiling of the dry storage area was made of unfinished plywood rendering an un-cleanable surface; and

* Door leading to the dry storage area was unfinished wood creating an un-cleanable surface.

3. Areas in need of repair:

* Interior and exterior particle board cupboards underneath steam table had exposed wood, making it an un-cleanable surface, and a cupboard door was off the hinges;

* A piece of wood was attached to a wall near the food steamer and commercial oven, which created a potential fire hazard;

* Control knobs missing from both ovens;

* Oven next to the food steamer was not working;

* Garbage disposal was not functioning;

* Continuous water leaking from three compartment sink faucet;

* The caulking along the back splash of the dishwashing area, kitchen sinks, counters, and baseboards was corroded, blackened or missing;

* Multiple floor tiles were chipped throughout kitchen areas;

* Hand washing sink soap dispenser and paper towel dispenser was empty;

* Janitor closet had a missing door handle, and splintered exposed wood was around the trim ring;

* Doors and door frames throughout the kitchen were gouged, scraped, and splintered;

* Kitchen back door had black smears, chipped paint, stains, scuffs, and the screen covering the door was torn, allowing potential entry of insects and pests;

* Patches of disintegrated drywall were between the floor and wall behind the dish machine;

* Walk-in cooler door gasket was torn and damaged;

* Interior side of the walk-in cooler door was significantly dented and had a one-inch diameter hole; and

* Self-serve ice and ice cream machines in the dining room were not working and were out of order.

At approximately 3:00 pm, the findings and areas of concern were reviewed and toured with Staff 1 (Administrator). At 3:16 pm, the survey team contacted the Community Based Care Manager and shared concerns about the unsanitary condition of the kitchen and dry food storage area. A decision was made to close the kitchen until the unsanitary condition was rectified.

At that time, the facility was informed that the kitchen would be closed down. Staff 1 was instructed by the survey team to submit a (NIC) needs immediate correction plan to address the unsanitary conditions and areas needing repair in the kitchen.

The facility submitted an initial NIC plan on 08/29/22 at 6:15 pm. The plan for how the facility would provide food to the residents for the next 24 hours was accepted; however, additional information was requested for the plan and was agreed to be reviewed the following day.

On 08/30/22, at approximately 12:09 pm, the facility provided additional information on how they were going to proceed to correct the unsanitary conditions of the kitchen. The plan indicated commercial cleaners were scheduled to come out to the facility at 7:00 am on 08/31/22. In the meantime, the kitchen remained closed.

On 08/31/22 at 10:00 am, the surveyor and Staff 1 re-inspected the kitchen. The unsanitary conditions found in the kitchen and dry storage had not been corrected; therefore, the kitchen remained closed. Due to the kitchen closure, the facility contracted with a mobile kitchen truck and the truck was scheduled to arrive on 09/01/22.

The facility was instructed to have a professional pest control company inspect the kitchen. The pest control report dated 09/01/22 was received on 09/02/22. The facility requested a re-inspection of the kitchen on 09/06/22.

On 09/06/22, at approximately 1:00 pm, the surveyor and Staff 32 (Regional Director) re-inspected the kitchen and dry food storage room and found the unsanitary conditions had been corrected. The facility planned to re-open the kitchen on 09/12/22 after the repairs were done. The facility plan was approved.

The need to ensure the kitchen was maintained in a sanitary manner and in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000, was discussed with Staff 32 on 09/06/22. He acknowledged the findings.

Resident Services Meals

1) Facility will schedule routine cleaning for hood, drains, appliances, floors and walls. New racks for the walk in dry storage and walk in cooler have been ordered.

2) Cleaning schedule will be implemented by facility for staff to complete daily, weekly and monthly.

3) Cleaning regimen and schedule to be reviewed monthly. Kitchen manager to review on a weekly bases.

4) Administrator or Designee, Kitchen Manager

*Additional Notation as requested by survey team:

A. Main kitchen area:

* Flies and gnats as noted on our walk-through, are not present. Rotten potatoes have been removed and no further issue has been noticed.

* Floors throughout the kitchen have been cleaned by outside provider and will be continuously cleaned by kitchen staff.

* Pipes, walls, gauges, disposal, drain, and flooring behind/underneath the dish machine and three compartment sink area have been thoroughly cleaned, the leak was repaired immediately however, this is on our construction crew list for a rebuild of the wall under the sinks.

* Pipes beneath cupboards and behind ice machine were covered with a layer of dirt, dust, and lint; this area was clean on our walkthrough together, FRP has since been installed.

* Walls and ceilings throughout the kitchen had multiple spills, smears, and food splatters;

* All garbage receptacles are covered and cleaned and will remain covered with ongoing training/checklists.

* Doors, door frames, ceiling, and walls had food splatters, spills, and stains. These areas have been cleaned and will be placed on routine schedule to clean for kitchen staff to follow.

* Exterior of ovens were covered in grease, food spills, orange and black sticky build up. These area were cleaned several times and will continue via checklists for the team.

* Interior of ovens had a buildup of burnt food debris, grease, and spills. These areas were cleaned several times and will continue to clean via checklists for the team.  Admin to review weekly

* Oven hoods have been cleaned by outside agency and will be maintained by kitchen staff.

* Floor drains have been thoroughly cleaned and emptied of any gray rotting matter.

* New shelves installed in walk in cooler.

* Kitchen janitor closet was thoroughly cleaned as noted in our walk-through, however, we have plans to replace flooring, repair tile, install a new mop basin, replace door and prep and paint walls

* Mechanical room will have drywall repaired and storage items removed. The drywall repair is added to our construction crew list.

* Undated and unlabeled food items were noted in the reach-in and walk-in cooler and freezer; This is no longer the case, all items are dated and labled.

* Rolling carts throughout the kitchen had loose food debris, dried liquid spills, and stuck food matter;

* Food boxes were stored on the walk-in and dry storage floors

* Multiple kitchen staff were observed not sanitizing hands upon entering the kitchen, nor washed hands between tasks, and were not consistently wearing face masks properly; and   As noted on your return visit, a training was immediately conducted for the team.  This will be an ongoing training and review by Admin weekly.

* Currently all kitchen staff members have their food handlers certifications with the exception of the two dishwashers.  Those dishwashers will have theirs within a week.  Ongoing, this will be a part of the onboarding process.

B. Dry food storage area:

* Extensive build-up of black matter/dirt/food debris was observed on the floor and behind/underneath shelving units. Shelving units have been replaced and flooring removed and replaced.

* Cardboard box of rotting potatoes stored on shelving unit was infested with gnats; This has been removed.

*Flies and Gnats in dry storage - as noted in our walk-through, this area was completely sealed up and painted as well as the entire storage area, see pictures sent via email.  In addition, new flooring was installed.

*Ceiling of dry storage was painted and sealed.

* Door leading to the dry storage area has been painted and is now a cleanable surface.

C. Areas in need of repair:

* Cabinets under steam table have been outfitted with cleanable surface to cover cubbies and is no longer used as a storage area.

* Pipe has been attached to the wall near the food steamer and commercial oven,

* We will be ordering one new oven unit and removing one, once the new unit is here.

* We are ordering a new oven unit, this is about 60 days out.

* Garbage disposal repaired and is functioning properly.

* Continuous water leaking from three compartment sink faucet;

* The caulking along the back splash of the dishwashing area, kitchen sinks, counters, and baseboards has been replaced or repaired.

* Multiple floor tiles of issue will be repaired/replaced by our construction team.

* Hand washing sink soap dispenser and paper towel dispensers are filled and will be going forward with checklists for the team.

* Janitor closet had a missing door handle, and splintered exposed wood was around the trim ring;   Referred to above as a new door will be installed.

* Doors and door frames throughout the kitchen will be evaluated and repaired or replaced as needed for gouging or splintering.

* Kitchen back door has been sanded, painted and FRP has been installed on the inside ½ of the door. This door will continue to be cleaned.

* Patches of disintegrated drywall will be addressed with the construction team.

* Walk-in cooler new gaskets will be installed by the vendor.

* Interior side of the walk-in cooler door was significantly dented and had a one-inch diameter hole; We agreed during the walk-through that this was aesthetics only and had no affect on the cooling of the walk-in.  

* Self-serve ice and ice cream machines in the dining room were not working and were out of order.  The ice machine has been removed completely and the ice cream machine is functional.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) and failed to ensure quarterly evaluations were accurate and used as the foundation to develop service plans for 3 of 4 sampled residents (#s 1, 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in March 2020.

Resident 4's 90-days nursing assessment, dated 6/3/21, failed to be reflective of the resident's condition in the following areas:

* Current left rib fracture;

* HHRN outside provider services for wound care; and

* Use of special shoe for the left foot.

The need to ensure evaluations were reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. No additional information was provided.

2. Resident 1 was admitted to the facility in July 2020.

Resident 1's 9/13/21 quarterly evaluation was not reflective of the resident's current condition in the following areas:

* Independence with care;

* Prosthetic use with HHPT guidance;

* HHRN providing wound care; and

* Type of insulin the resident self administered.

The need to ensure evaluations were accurate and reflective of the resident's condition was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

3. Resident 3 was admitted to the facility in October 2020.

Resident 3's quarterly evaluation was dated 7/26/21. The resident's service plan was dated 7/20/21.

The facility failed to ensure Resident 3's evaluation was used as the foundation to create the service plan as it was done after the service plan was created.  

The need to ensure evaluations are the foundation used to develop the service plan was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

4. Resident 5 was admitted to the facility in August 2021. The move in evaluation was reviewed and was identified to be missing the following required elements:

* Spiritual, cultural preferences and traditions;

* Memory, orientation and confusion and decision making abilities;

* Dental status;

* Nutritional habits including fluid preferences;

* History of dehydration or unexplained weight loss or gain; and

* Recent losses.

On 9/16/21 the need to address all required elements on the move in evaluation was discussed with the Staff 1 (Administrator) and Staff 2 (Resident Care Manager) who acknowledged the findings.

OAR 411-054-0034 (2-4) Resident

Move-in and Eval: Res Evaluation

1. Evaluations for residents 1, 3, 4 and 5 will be audited for all required elements and to assure information is reflective of current resident conditions.

2. RCC will be educated on evaluation areas of concern and evaluations for residents 1, 3, 4, and 5 will be updated to reflect current needs and eval to be used as foundation for plan of care.

3. Evaluations for all residents will be reviewed quarterly to assure accuracy, and used as foundation for plan of care.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 7) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 7 was admitted to the facility in January 2022. The move-in evaluation was reviewed and was identified to be missing the following required elements:

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting, room temperature.

On 02/11/22 the need to address all required elements on the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN). They acknowledged the findings.

1. Move-in evaluation for resident #7 has been reviewed and missing elements of need have been implemented. Evaluations will be audited for all required elements and implemented as necessary.

2. Care Coordinator and health services management will be trained on implementing move-in requirement into current care planning software.

3. Evaluations will be reviewed as they are completed for one month and then quarterly.

4. Administrator or designee to monitor.

3. Resident 4 was admitted to the facility in March 2020.

Resident 4's service plan, updated 8/26/21, and subsequent temporary service plans were reviewed during the survey and were not reflective of the resident's current status or failed to provide specific instruction to staff in the following areas:

* Pain management due to new onset of chest pain and neck pain;

* Fall preventions;

* Signs and symptoms of how they exhibit behaviors;

* Outside provider services including who to report and when to report;

* Use of a special shoe on the left foot;

* Use of a side rail while in bed;

* Oxygen use including who changes tubing and filter; and

* Resident specific signs and symptoms of having low or high blood sugar.

The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, handwritten updates were dated and initialed and were updated quarterly for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2020.

Resident 1's service plan was reviewed and was not reflective or lacked clear caregiving instruction in the following areas:

* Daily blood pressure checks and which arm to take blood pressures on;

* Prosthetic teaching;

* Anxiety and if the resident could request a PRN, what the signs and symptoms are and any non-drug interventions to offer;

* Dialysis relating to care needs before and after, location, transportation, and food provided by the facility;

* Mental health and preference of the door and window being open;

* Breakfast routines; and

* Resident specific signs and symptoms of having low or high blood sugar.

The resident's service plan that was available to staff was dated 5/27/2021. The facility had not updated the document quarterly. There were two handwritten updates. One lacked a date and initials of the staff member who made the changes.

The need to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding the delivery of services, handwritten updates were dated and initialed and were updated quarterly was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in October 2020.

Resident 3's service plan, dated 7/20/21, was reviewed and was not reflective or lacked clear caregiving instruction in the following areas:

* Fall interventions;

* Breakfast habits and preferences;

* Signs and symptoms of how they exhibit anxiety;

* Non-drug interventions relating to anxiety;

* After care instructions for a pelvic fracture; and

* Unclear directions relating to dressing, transfers and toileting.

The need to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

4. Resident 5 was admitted to the facility in August 2021 with a diagnosis of hypertension. The resident was identified in the acuity interview as being administered Warfarin (blood thinner).

The resident's 8/30/21 service plan was reviewed and was not reflective and did not include clear instruction for staff in the following areas:

* Routine lab draws and;

* Warfarin administration including common side effects and risks.

The need to ensure service plans were reflective of resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manger) on 9/16/21. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan:

General

1. Service plans will be audited and reviewed for accuracy and corrected as needed for residents 1, 3, 4 and 5. Evaluations will be completed to reflect the current resident condition and then used for foundation of service plan.

2. Service plans will be audited and reviewed going forward for accuracy.

3. This will be reviewed prior to date of alleged compliance as well as quarterly going forward.

4. The administrator or designee will be responsible for monitoring and auditing service plans.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 1 of 3 sampled residents (# 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2015 with end stage renal disease. The residents service plan, dated 02/03/22, was reviewed and was not reflective or lacked clear care giving instruction in the following areas:

* Location of fistula and which arm to take blood pressures on;

* Use and placement of a sling for use by the resident on dialysis treatment days;

* Mobility, left-sided weakness and need for two person-assist during transfers;

* Resident's current plan for desired weight loss;

* Directions regarding CBG readings and insulin administration; and

* Recent fall and current fall interventions specific to the resident.

During observations and interviews on 02/11/22, Resident 6 was up in a wheelchair, had a fistula in his/her right upper arm and stated s/he goes to dialysis three times a week and returns to the facility at about 9:00 pm, some of his/her medications are not to be taken on days s/he goes to dialysis and the resident is able to self-direct certain aspects of his/her care. Resident 6 stated some staff "are good about knowing how to take care of me and others are not. I have to tell them each step of what needs to be done."

The need to ensure service plans were reflective of residents' needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 02/15/22. They acknowledged the findings.

1. Resident #6 service plan has been updated to reflect current plan of care and communication has been established between providers to ensure changes to plan of care are implemented in timely manner. All Service plans will be audited and reviewed for accuracy and corrected. Evaluations will be completed to reflect the current resident condition and needs.

2. Service plans will be audited and reviewed going forward for accuracy.

3. This will be reviewed quarterly.

4. The administrator or designee will be responsible for monitoring and auditing service plans.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure and hypertension.

During the acuity interview on 08/29/22, Resident 11 was was identified with a history of falls, and a recent fall resulting in a head injury.

Observations and interviews with the resident and staff from 08/29/22 to 08/31/22, review of clinical record and most recent service plan, dated 07/27/22, indicated the service plan failed to reflect the resident's current care needs and lacked specific instruction to staff in the following areas:

* Recent falls and interventions;

* Significant change of condition related to a fall on 08/26/22, sustained a head injury;

* Cognition, including memory, orientation, confusion and decision making ability;

* Current skin condition; and

* Pain areas, indicators of pain, pharmaceutical and non pharmaceutical interventions.

The need to ensure service plans were reflective of residents' current needs and provided specific instruction to staff was discussed with Staff 1 (Administrator) on 08/31/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff for 2 of 2 sampled residents (#s 11 and 12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 09/2021 with Type 2 Diabetes.

The residents service plan, dated 07/11/22 and Interim Service Plans (ISP's) were reviewed during the survey.

During observations and interviews on 08/30/22, Resident 12 had a hospital bed with bilateral 1/4 length side-rails in the up position. The resident was seated in a wheelchair and was alert, oriented and able to report on his/her care needs.

The service plan was not reflective or lacked clear care giving instruction in the following areas:

* Mobility, including escorts to and from the dining room (resident was independent);

* Need for one-to-two person-assist during transfers;

* Use of bilateral side rails, risk and instructions for use;

* Need for one person dressing assistance;

* Increased weakness and pain;

* Self administering CBG readings and insulin (staff assisted); and

* Current fall interventions specific to the resident.

The need to ensure service plans were reflective of residents' needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SERVICE PLAN GENERAL

1) Resident 11's service plan was reviewed and updated to reflect current plan of care.

2) All Service plans will be audited and reviewed for accuracy and corrected. Evaluations will be completed to reflect the current resident condition and needs.

3) This service plan will be reviewed quarterly.

4) The administrator or designee will be responsible for monitoring and auditing service plans.

4. Resident 4 was admitted to the facility in March 2020.

The resident's clinical records dated 6/28/21 through 9/9/21 indicated the following:

a. On 6/28/21 staff documented in a facility progress note that the resident "had an injury fall ... [in the] bathroom..." Resident was sent to an emergency department and returned to the facility on the same day.

The resident had experienced a fall. The facility failed to evaluate the fall risk to determine and document what action or intervention was needed for the resident.

b. On 7/2/21 staff documented the resident was sent to the hospital due to complaint of chest pain and returned to the facility on the same day with a new diagnosis of a left rib fracture.

On 9/16/21 at 9:45 am, Staff 2 (Resident Care Manager) stated the diagnosis of the left rib fracture was sustained by the 6/28/21 fall.

There was no documented evidence the resident was evaluated to determine what action or intervention was needed regarding the left rib fracture and no evidence the resident's change of condition was monitored through resolution.

c. During the acuity interview on 9/14/21, Resident 4 was identified to have an open wound on his/her left foot and received HHRN for wound care.

On 7/27/21, staff documented "bottom of left foot with 100 % granulation. Small amount of serosanguineous drainage. Measure 2.3 x 2.2 x 0.3 cm ..."

There was no documented evidence of weekly skin monitoring between 7/27 and 8/28/21.

The need to ensure the facility monitored residents' changes of condition weekly through resolution, including determining new actions or interventions was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

3. Resident 3 was admitted to the facility in October 2020.

Progress notes dated 6/16/21 through 9/8/21 were reviewed.  Resident 3 had a fall on 9/1/21, was sent to the emergency room and returned the same day.  The "After Visit Summary" dated 9/1/21 and received by the facility on 9/9/21, noted the resident had a pelvic fracture.

There was no documented evidence the facility evaluated the resident's change of condition and determined if actions/interventions were needed.

The need to ensure the facility monitored residents' changes of condition through resolution, including implementing new interventions and monitoring those interventions for effectiveness, was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 3 (RN) during the survey. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, weekly monitoring until the condition resolved, and documented evidence of a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action for 4 of 4 sampled residents (#s 2, 3, 4 and 5) who experienced changes of condition. Resident 2 experienced significant and ongoing weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in July 2018 with diagnoses including obesity and major depressive disorder.

The resident's 12/1/20-9/15/21 progress notes, 4/28/21 physician's orders, incident reports, Interim Service Plans (ISP's), weight records spanning from 8/2019 through 9/15/2021 and 9/1/21 through 9/13/21 MARs were reviewed.

Resident 2's weight record revealed the following:

* 12/14/20 - 159 pounds;

* 1/8/21 - 152 pounds;

* 4/3/21 - 148.6 pounds;

* 5/8/21 - 146.2 pounds;

* 6/10/21 - 132.4 pounds; and

* 9/15/21 - 114 pounds.

From 1/2021 to 4/2021, Resident 2 lost 3.4 pounds. The resident received a 4/28/21 physician's order for the facility to increase the administration for one bottle of Ensure (nutritional supplement) from once daily to twice daily.

The facility lacked documented evidence they monitored the increase of the nutritional supplement to determine if it was effective in addressing the resident's weight loss.

Between 5/2021 to 6/2021 the resident lost an additional 13.8 pounds or 9.43% of his/her body weight in one month. This represented a severe loss.

Between 6/2021 to 9/15/21 the resident lost an additional 18.4 pounds or 13.89% of his/her body weight in a three month period. The resident continued to experience a severe weight loss.

Observations made during lunch on 9/16/21 found the resident ate 25% of the meal before asking staff for an escort out of the dining area.

There was no documented evidence in the residents records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment.

During an interview on 9/15/21 with Staff 3 (RN), she stated the facility's system did not alert her to the resident's severe weight loss.

The facility's failure to have an effective monitoring system in place to monitor Resident 2's weight loss contributed to the resident's severe ongoing weight loss.

2. Resident 5 was admitted to the facility in August 2021. The resident's 8/16/21 through 9/13/21 progress notes were reviewed and revealed the following:

* The resident experienced a non-injury fall on 8/26/21 and;

* On 9/1/21 staff charted an observation of large bruising underneath the resident's arm and lower waist area. The resident informed staff s/he had fallen down the staircase and hit his/her head.

The facility lacked documented evidence it determined and documented what action or interventions were needed for the resident's falls, skin condition, or injury to his/her head, communicated the actions or interventions to staff on each shift, or monitored each at least weekly through resolution.

During a 9/16/21 interview with Staff 2 (Resident Care Coordinator), she confirmed the resident's falls, skin condition and head injury were not evaluated or monitored by the facility.    

The facility's failure to effectively monitor, evaluate, determine what actions or interventions were necessary for resident's with short term changes of condition, communicate the interventions to staff on each shift, refer significant changes of condition to the RN for assessment and monitor interventions for effectiveness was discussed with Staff 2 (RN) on 9/15/21 and Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of

Condition and Monitoring

1. RN to complete the OHCA course "role of the RN"

2. RN will be educated on proper change of condition and monitoring and required elements for these concerns. Clinical meetings will review all residents for any possible changes of condition.

3. Clinical meetings held at least weekly, check ins for resident condition to be completed at least 3 times per week.

4. Administrator or designee to monitor.

3. Resident 9 was admitted to the facility in January 2021.

Resident 9's progress notes dated 01/14/22 through 02/10/22 revealed the resident experienced the following change of condition:

* On 02/04/22 - fall with injury which resulted in back pain.

There was no documented evidence the facility determined and documented what resident specific action or interventions were needed to address the resident's fall and failed to monitor the residents pain with weekly progress noted until resolved.

The need to ensure the facility had a system to determine if new interventions were needed and monitor interventions for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/14/22. They acknowledged the findings.

2. Resident 10 was admitted to facility in October 2020.

Resident 2's progress notes, dated 01/13/22 through 02/10/22, revealed the resident experienced the following new changes of condition:

* On 01/31/22 -  fall with injury;

* On 02/04/22 -  fall with injury; and

* On 02/10/22 -  a non-injury fall.

There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to address the resident's falls and help prevent future falls.

The need to ensure the facility had a system to determine if new interventions were needed and monitor interventions for effectiveness was reviewed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/14/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift and weekly monitoring until the condition resolved, for 3 of 3 sampled residents (#s 6, 9 and 10) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 2015 and had a stroke in 2021. The resident's 01/14/22 through 02/11/22 progress notes and temporary service plans were reviewed and revealed the following short term changes of condition:

* The resident experienced a fall on 01/20/22 and sustained an abrasion to the arm; and

* The resident was receiving wound care for chronic skin breakdown to the buttock area.

The clinical record lacked documented evidence of:

* what action or interventions were needed following the resident's fall to prevent further falls;

* documentation of monitoring of the skin wounds at least weekly through resolution.

During a 02/15/22 interview, Staff 15 (RN) stated Resident 6 was receiving home health services for skin wounds and the home health notes were reviewed weekly by the facility RN, however the facility RN was not observing the wounds weekly. The resident's fall interventions and skin conditions were not monitored at least weekly by the facility.  

The need to evaluate, determine what actions or interventions were necessary for resident's with short term changes of condition and monitor the interventions for effectiveness was discussed with Staff 1 (Administrator) and Staff 15 on 02/15/22. They acknowledged the findings.

1. Resident #s 6, 9 and 10 records have been reviewed and change in condition documentation and interventions have been implemented. RN and health services management team has been trained on areas of need for required elements and procedure for change of condition.

2. Clinical meetings twice weekly to review resident services and identify changes in condition.

3. will review quality assurance once monthly to assure changes are identified and procedure is implemented.

4. Administrator or designee to monitor.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure, hypertension, atrial fibrillation, and vitamin D deficiency.

During the acuity interview on 08/29/22, Resident 11 was identified as a fall risk and had a recent fall that resulted in a head injury.

The resident's current service plan,  interim service plans, incident reports, charting notes and RN assessments were reviewed during the survey.

Resident 11's 07/27/22 service plan indicated that resident had a history of falls and a fall prevention program was in place and staff were to follow the fall prevention program.

Interviews with staff during the survey revealed there were no resident specific fall interventions in place or fall program instructions for the staff to follow.

On 08/26/22, staff heard the resident calling for help from her/his apartment and found the resident on the floor with an open wound in the back of his/her head.  The resident was sent to the emergency room and returned to the facility the following day with ten staples in the back of his/her head.

There was no documented evidence the facility evaluated the resident, determined what resident specific actions or interventions were needed following the fall, communicated the actions and interventions to staff on all shifts and updated the service plan as needed.

The need to ensure resident specific actions or intervention were developed after a fall, and they included resident specific instructions for staff was discussed with Staff 1(Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift and weekly monitoring until the condition resolved, for 2 of 2 sampled residents (#s 11 and 12) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to facility in 09/2021 with Type 2 Diabetes.

Progress notes dated 07/13/22 through 08/29/22, service plan dated 07/11/11 and Interim Service Plans (ISP's) were reviewed during the survey.

Resident 12's current service plan noted the following fall interventions:

* Transfer pole in bathroom;

* Grab bars in shower;

* Very frequent checks; and

* Shower chair.

The following changes of condition were identified:

* On 07/16/22 - Injury fall with skin tear to chin and lip;

* On 08/05/22 - Injury fall with abrasion to the right side of back;

* On 08/23/22 - Injury fall with scratches to the forearm and hand;

* On 08/27/22 - Non-injury fall;

* On 08/29/22 - Injury fall with skin tear to right forearm; and

* On 08/29/22 - Hypoglycemic event.

There was no documented evidence the facility determined and documented what resident specific actions or interventions were needed to address the resident's falls or reviewed the service planned interventions for effectiveness.

Additionally, there was no documented evidence the facility monitored the residents condition through resolution when his/her CBG's were outside of baseline.

The need to ensure the facility had a system in place to monitor interventions for effectiveness, determine if new interventions were needed and monitored changes of condition through resolution was reviewed with Staff 1 (Administrator), Staff 10 (Resident Care Coordinator) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

CHANGE OF CONDITION AND MONITORING

1) Evaluations have been completed for residents 11 and 12 to address current needs and reflect resident specific instructions and interventions.

2) Nurse will review all chart notes at least twice weekly and implement changes and interventions as needed.

3) Quality Assurance meeting held monthly.

4) Administrator or designee

3. Resident 4 was admitted to the facility in March 2020.

Clinical records were reviewed and revealed Resident 4 sustained a fall on 6/28/21 which resulted in fractured left rib which represented a significant change of condition that required an RN assessment.  

An RN assessment was requested on 9/14/21 during the survey. On 9/15/21 at 3:00 pm, Staff 2 (Resident Care Manager) confirmed there was no RN assessment for the change of condition.

The need to document an RN assessment for significant changes of condition was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.  

2. Resident 3 was admitted to the facility in October 2020.

Clinical records were reviewed and revealed Resident 3 sustained a fall on 9/1/21 which resulted in a fractured pelvis.

An RN assessment was requested on 9/14/21. On 9/15/21 at 2:11 pm, Staff 3 (RN) confirmed there was no RN assessment for the significant change of condition and was not aware one needed to be completed.

The need to document an RN assessment for significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 during the survey. They acknowledged the findings.  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN assessed all residents with a significant change of condition, and documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff for 3 of 3 sampled residents (#s 2, 3 and 4) who experienced a significant condition. Resident 2 experienced severe weight loss.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in July 2018 with diagnoses including obesity and depression.

From 1/2021 to 4/2021, Resident 2 lost 3.4 pounds or 13.89% of his/her body weight in 3 months. This represented a significant change of weight loss that required an RN assessment.  Between 5/2021 and 9/15/21 the resident continued to lose weight.

The facility lacked documented evidence the RN assessed Resident 2 for the significant change of condition.

The requirement for the facility to ensure an RN assessed residents experiencing  significant changes of condition, documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff was discussed with Staff 3 on 9/15/21, Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.   

Refer to C270, example 1.

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

Resident Health Services

1. Residents 2, 3 and 4 have been assessed for significant changes of condition and required elements are in place. RN to attend the Role of RN class.

2. Clinical meetings held at least weekly will review pertnient information to indicate possible changes of condition, nurse will evaluate as needed.

3. This will be reviewed no less than weekly.

4. The administrator to review and monitor.

2. Resident 11 was admitted to the facility in 09/2021 with diagnoses including congestive heart failure.

Progress notes dated 07/11/22 through 08/29/22, incident reports, current service plan, interim service plans and RN assessments were reviewed during the survey. The following deficiency was identified:

On 08/26/22, the resident had a fall with injury and sustained an open wound to the back his/her head. The resident returned to facility with with ten staples in the back of his/her head.

The resident's head injury represented a significant change of condition.

The RN documented a significant change of condition assessment on 08/27/22; however, the assessment failed to include findings, resident status and interventions made as a result of the assessment. The resident's service plan was not updated.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment and the resident's service plan was updated was discussed with Staff 1 (Administrator) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN assessed all residents with a significant change of condition, and documented findings, resident status, and interventions made as a result of the assessment, and communicated the actions or interventions to staff for 2 of 2 sampled residents (#s 11 and 12) who experienced a significant change in condition. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 9/2021 with diagnoses including Type 2 Diabetes and history of broken femur.

During the entrance conference it was reported the resident had a change in condition and now needed one-to-two person transfers and generally needed additional assistance from caregivers.

Between 07/13/22 through 08/29/22, the resident had five falls, experienced increased pain, weakness, inability to transfer independently,  provide his/her own incontinent care and now required the use of a wheelchair. This represented a significant change of condition that required an RN assessment.

There was no documented evidence the facility RN completed a timely assessment that documented the resident's current condition, status, findings and interventions made as a result of the assessment. Additionally, there was no documented evidence the service plan was updated after the resident had a significant change of condition.  

The need to ensure the facility RN completed an assessment for a significant change in condition was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant). They acknowledged the findings.

RESIDENT HEALTH SERVICES

1. Resident 11 and 12 charts have been reviewed and residents re-evaluated for current needs and proper resident-specific interventions in place.

2. Nurse to review all chart notes at least twice weekly and ensure implementation and interventions occur.

3. This will be reviewed monthly.

4. Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the 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 9/14/21, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Interviews with staff, delegation records and the 9/1/21 -  9/14/21 MAR revealed the following:

* Staff 10 (MT) and Staff 11 (MT) lacked documented evidence an individual observation/return demonstration of competence of the staff to determine if the staff remains capable and willing to safely perform the task.

* Staff 11 documented on the MAR she administered Resident 4's insulin injection on 9/5/21, 9/7/21, 9/8/21, 9/9/21, 9/11/21 and 9/13/21. The last evaluation for  Staff 11's skills and ability was completed on 11/26/20 and scheduled for re-evaluation on 5/26/21. There was no documented evidence of re-evaluation of the delegation task for Resident 4 had been completed as of 9/16/21.

* Staff 12 (MT) documented on the MAR he administered Resident 4's insulin injection on 9/1/21, 9/2/21, 9/5/21, 9/6/21, 9/8/21, 9/9/21, 9/10/21, 9/12/21, 9/13/21  and 9/14/21. The last evaluation for Staff 12's skills and ability was completed on 7/12/21 and scheduled for re-evaluation on 9/12/21. There was no documented evidence of re-evaluation of the delegation task for Resident 4 had been completed as of 9/16/21.

The requirements for delegation were reviewed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. They acknowledged the findings.

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

Delegation and Teaching

1. RN to attend OHCA Role of RN class.

2. RN will be educated on delegation and teaching requirements and will audit delegation files to assure complaince.

3. This will be audited by date of alleged compliance and every 6 months.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 6) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 02/10/22, Resident 6 was identified to be administered insulin injections by non-licensed staff.

Interviews with staff, delegation records and the 01/01/22 -  02/11/22 MAR revealed the following:

1. Staff 20 (MT) administered insulin to Resident 6 on 01/20, 01/24, 01/28 and 02/10/22. The records lacked documented evidence of Staff 20 being delegated to administer insulin to Resident 6.

In a phone interview on 02/11/22, Staff 3 (RN) confirmed that Staff 20 had not been delegated to provide insulin for Resident 6.

2. Delegation documentation showed the following:

a. Staff 12 (MT) had an initial delegation on 11/23/21. The next delegation was scheduled for 180 days later on 5/23/22. This exceeded the 60 day required re-evaluation period following the initial delegation;

b. Staff 22 (MT) had an initial delegation on 10/02/21. The next delegation was scheduled for 180 days later on 4/02/22. This exceeded the 60 day required re-evaluation period following the initial delegation; and

c. Staff 23 (MT) had an initial delegation on 01/19/22. The next delegation was scheduled for 180 days later. This exceeded the 60 day required re-evaluation period following the initial delegation.

During an interview on 02/11/22, Staff 1 (Administrator) and Staff 15 (RN) stated the documentation of the intial delegation may have been inaccurate and that Staff 12, 22 and 23 had been previously delegated. No other documentation was provided.

3. Delegation documentation was reviewed on 02/11/22 and showed the following inaccuracies:

a. Staff 12 (MT) had been re-evaluated by the RN on 05/23/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed;

b. Staff 8 (MT) had been re-evaluated by the RN on 05/29/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed;

c. Staff 24 (MT) had been re-evaluated by the RN on 03/30/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed; and

d. Staff 22 (MT) had been re-evaluated by the RN on 04/02/22. The re-evaluation was signed by the RN and the "justification for reassessment" had been completed.

During an interview on 02/11/22 with Staff 1 and Staff 15 it was discussed that the delegations cannot be dated in advance.

The requirements for delegation and the need to ensure accurate documentation was provided were reviewed with Staff 1 and Staff 15 during the survey. They acknowledged the findings.

1. Delegation records have been reviewed for resident #6 and all staff has been delegated for this resident. Delegation forms have been revised to include all required elements of delegation training.

2. Delegations will all be completed using new forms.

3. Delegations will be reviewed as part of quality assurance meetings.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 12) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 08/29/22, Resident 12 was administered insulin injections by non-licensed staff.

Interviews with staff, review of delegation records and the 08/01/22 - 08/29/22 MAR revealed the following:

1. On seven occasions, Staff 25 (MT) recorded CBG's and administered insulin to Resident 12. The records lacked documented evidence of Staff 25 being delegated to administer insulin to Resident 12.

2. On 13 occasions, Staff 28 (MT) recorded CBG's and administered insulin to Resident 12. The records lacked documented evidence Staff 28 was delegated to administer insulin to Resident 12.

3. Delegation documentation showed the following:

a. Staff 8 (MT/Assistant RCC) had an initial delegation on 04/03/22. At the time of survey on 08/29/22, Staff 8 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation;

b. Staff 20 (MT) had an initial delegation on 04/01/22. At the time of survey on 08/29/22, Staff 8 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation; and

c. Staff 12 (MT) had an initial delegation on 05/14/22. At the time of survey on 08/29/22, Staff 12 had not been reevaluated. This exceeded the 60 day required re-evaluation period following the initial delegation.

The requirements for delegation and the need to ensure accurate documentation was reviewed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) during the survey. They acknowledged the findings.

RN DELEGATIONS AND TEACHING

1. Delegation records have been reviewed for resident #12 and all staff has been delegated for this resident.

2. Delegating RN trained in performing and documenting delegation. Delegating nurse will be attending role of the RN class.

3. Delegations will be reviewed by nurse consultant at each visit.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 17) who received insulin injections by unlicensed facility staff. This is a repeat citation. Findings include, but are not limited to:

During the acuity interview on 04/04/23, Resident 17 was identified to be administered insulin injections by non-licensed staff.

Interviews with staff, review of delegation records and the 03/01/23 - 04/04/23 MAR revealed the following:

* Staff 25 (MA) documented on the MAR she administered Resident 17's subcutaneous injection. The evaluation for Staff 25's skills and ability was completed on 10/23/22 and scheduled for re-evaluation in 120 days or no later than 02/20/23. The re-evaluation of the delegation task was completed on 03/15/23, 23 days after it was scheduled; and

* Staff 28 (MA) documented on the MAR she administered Resident 17's subcutaneous injection. The evaluation for Staff 28's skills and ability was completed on 10/21/22 and scheduled for re-evaluation in 120 days or no later than 02/18/23. The re-evaluation of the delegation task was completed on 03/29/23, 45 days after it was scheduled.

The requirements for delegation were reviewed with Staff 27 (LPN Consultant), Staff 34 (Administrator) and Staff 35 (RN) during the survey. They acknowledged the findings.

C282: Cornell Estates Plan of Correction

 What actions will be taken to correct the rule violation?

Facility new RN will be taking delegation course on 4/12/23 and will be taking Role of the RN through OHCA on 5/9/2023 - 5/11/2023. Delegation training on 4/12/23 has been completed already.

How will the system be corrected so this violation will not happen again?

Monthly evalutions of the delegation binder and tracking form will be reviewed

RN was supplied a Delegation tracker for RN to utilize

How Often with the area needing correction be evaluated?

Administrator and will review tracker and delegation packet monthly to ensure delegation match RN plan for delegations

Who will be responsible to see the corrections are completed/monitored?

Administrator & Resident Care coordinator    

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 1 sampled resident (# 3) who had pelvic fracture home care instructions. Findings include, but are not limited to:

Resident 3 was admitted to the facility October 2020. The resident's progress notes dated 6/16 through 9/8/21, service plan, ISP (interim service plans) and the quarterly evaluation were reviewed.

Documentation revealed Resident 3 had a fall on 9/1/21 and was sent out to the hospital. The "After Visit Summary" dated 9/1/21 noted the resident sustained a pelvic fracture. There were aftercare instructions included in the summary the hospital printed.

On 9/15/21, both Staff 2 (Resident Care Manager) and 3 (RN) confirmed the hospital's recommendations were not passed on to the staff for the provision of care for Resident 3's pelvic fracture.

The need to ensure the coordination of care with outside providers in order to ensure the continuity of care, including hospital home care instructions, were communicated to caregiving staff was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings.

OAR 411-054-0045(2) Res Hlth Srvc:

On- and Off-Site Health Srvc

1. Res 3 condition has been evaluated. Evaluation and subsequent service plan are reflective of resident's condition.

2. Clinical meetings implemented to review resident needs and outside provider recommendations.

3. Outside provider recommendations to be reviewed daily and implemented in interim service plan or change of service plan as needed.

4. Administrator or designee to monitor.

Based on observation, interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system. Findings include, but are not limited to:

Refer to C303, C305, C310 and C325.

OAR 411-054-0055 (1)(a) Systems:

Medications and Treatments

1. Clinical meetings to be held at least weekly and medications will be reviewed. 3 step check system will be implemented for all new orders.

2. The current system will be enhanced to include 3 steps for checking new orders for accuracy in the MAR.

3. This will be reviewed at least weekly

4. Administrator or designee will hold clinical meetings and monitor this system.

Based on interview and record review, it was determined the facility failed to ensure it had a safe medication system approved by a pharmacist consultant, registered nurse, or physician and failed to ensure adequate professional oversight of the medication system. This is a repeat citation. Findings include, but are not limited to:

1. During the re-visit survey, the 01/01/22 through 02/10/22 MARs were reviewed for multiple residents (#'s 6, 9 and 10). The MARs lacked specific medication administration times for multiple medications, including some medications with time sensitive parameters.

Interviews with Staff 1 (Administrator), Staff 15 (RN) and Staff 2 (Resident Care Manager) on 02/10/22 and 02/11/22 revealed the following:

* Physician orders were reviewed by unlicensed staff and the facility lacked a system for the RN or other licensed staff to consistently review physician orders;

* The facility lacked a system for routine audits of the MAR; and

* The facility was unable to identify whether an RN, pharmacist or physician was providing oversight of the current medication system.

2. During the re-visit survey, conducted 02/10/22 through 02/15/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 303: Systems: Medication and Treatment Order;

* C 305: Systems: Resident Right to Refuse;

* C 310: Systems: Medication Administration; and

* C 330: Systems: Psychotropic Medications.

3. Resident 9 was admitted to the facility in January 2021 with a diagnosis of hypotension.

A physician's order for Midodrine (for low blood pressure), dated 1/4/22, instructed staff to administer the medication from 8:00 am-10:00 am, 10:00 am-12:00 pm, and 2:00 pm, and included parameters to "administer doses in three to four hour intervals."

Medication administration times for Midrodrine were requested, however the facility was unable to provide documented evidence of actual administration times.   

On 02/11/22, Staff 1 (Administrator) and Staff 15 (RN) stated the MT's were having issues with internet connectivity and they were not able to fully sign out the medications until after they completed the entire medication pass for all residents. Once the MT returned to the nurses' desk to connect to the internet they were allowed to save the medication pass time. Staff 1 stated this could be hours later and may reflect that the 8:00 am medication pass was given at the same time as the 10:00 am medication pass.

On 02/15/22, Staff 1 stated the facility "added hotspots to each floor to address the internet connectivity issue."  

The need to ensure the facility had a safe medication system that documented specific medication administration times was discussed with Staff 1 and Staff 15 on 02/15/22. They acknowledged the findings.

1. MARs were reviewed of residents #s 6, 9 and 10. for specific administration times and time sensitive parameters put in place. Consultant RN will review medication services and advise other necessary changes to systems as needed.

2. Systems to be implemented as advised by consultant RN. A staff member will be trained and designated as med tech trainer to ensure all med techs are trained according to systems and regulation.

3. this will be reviewed monthly in quality assurance meetings.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. This is a repeat citation.  Findings include, but are not limited to:

During the second revisit survey, conducted 08/29/22 through 08/31/22, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 282: Systems: RN Delegation;

* C 303: Systems: Medication and Treatment Orders;

* C 305: Systems: Resident Right to Refuse; and

* C 310: Systems: Medication Administration.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SYSTEMS MEDICATIONS & TREATMENTS

Refer to C282, C303, C305, C310

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 5 sampled residents (#s 1, 2, 3 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2020. The resident's September 1 through 14, 2021 MAR, TAR and current physician orders were reviewed.

a. The following medications had current physician's orders but showed as discontinued on the MAR:

* Lanthanun (for kidney disease);

* Novolog (for diabetes);

* Trazadone (for insomnia);

* Clotrimazole (fungal treatment);

* Wound care, twice weekly, to right heel;

* Bisacodyl (for constipation); and

* Daily skin checks to right foot and left stump.

b. There were two orders, both dated 9/9/21, one from the physician and the other from the pharmacy relating to the medication, hydrocod/APAP (for pain). The pharmacy showed an active order, however the hand-written order from the physician directed the facility to discontinue the medication. The resident received one hydrocod/APAP tablet on 9/11/21. It was not clear if the resident received a discontinued medication.

On 9/15/21 at approximately 12:30 pm, Staff 2 (Resident Care Manager) and Staff 3 (RN) confirmed the prescriber had not been contacted to clarify the order.

c. Resident 1 had a physician's order for Levothyroxine (for hypothyroidism) to be administered on Tuesday, Thursday, Saturday and Sunday at 11:00 am. The MAR reflected the medication could be administered between 10:00 am and 12:00 pm.  However, the medication was identified as time sensitive, and must be administered at least 30 to 60 minutes prior to eating.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings.

2. Resident 3 was admitted to the facility in October 2020. The resident's September 1 through 14, 2021 MAR, TAR and current physician orders were reviewed.

Resident 3 sustained a pelvic fracture on 9/1/21. S/he requested a PRN for pain on 9/4/21. The resident had two PRN pain medications ordered prior to the fracture, acetaminophen and Tramadol.

Per a progress note dated 9/4/21, when staff looked to see what the resident could have for pain, she noticed the only medication available was the PRN acetaminophen. When the staff member attempted to administer the PRN acetaminophen, the resident refused, stating, "Tylenol isn't strong enough, it doesn't work, get them out of here." The same progress note dated 9/4/21 stated the PRN Tramadol was not available to staff to administer to the resident at that time, indicating the physician's order could not be carried out as prescribed.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 during the survey. They acknowledged the findings.  

3. Resident 2 was admitted to the facility in July 2018. Residents 2's 4/28/21 physician's orders and 9/1/21 through 9/13/21 MARs were reviewed and revealed the following:

Resident 2 had a physician's order for daily blood pressure checks and parameters for staff to inform the physician of readings over 140/90.

* On 9/2/21 the residents blood pressure was documented as 144/51; and

* On 9/11/21 the residents blood pressure was documented as 143/71.

The facility lacked documented evidence the physician was notified when the resident's blood pressure was outside of parameters.

During a 9/15/21 interview with Staff 2 (Resident Care Manager), Staff 2 confirmed the physician had not been notified when the residents blood pressure was outside of parameters.

The need to ensure physician's or other legally recognized prescriber's orders were followed was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

4. Resident 5 was admitted to the facility in August 2021. The resident's 8/30/21 physician's orders and 9/1/21 through 9/13/21 MAR were reviewed and revealed the following:

Resident 5 had a physician's order for daily weights and instructions for the facility to administer furosemide (diuretic) one 20 mg tab daily if the resident had weight gain of more than three pounds daily. The MAR lacked documentation of the residents weights on the following dates: 9/1/21, 9/2/21, 9/5/21, 9/6/21, 9/8/21, 9/9/21, 9/10/21 and 9/13/21.

During a 9/15/21 interview with Staff 2 (RN), she confirmed the weights had not been obtained.

The need to ensure physician's or other legally recognized prescriber's orders were followed was discussed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems:

Treatment Orders

1. Clinical meetings to be held at least weekly and treatment will be reviewed. 3 step check system will be implemented for all new orders.

2. The current system will be enhanced to include 3 steps for checking new orders for accuracy in the MAR.

3. This will be reviewed at least weekly.

4. Administrator or designee will hold clinical meetings and monitor this system.

3. Current physician's orders, the 02/01/21 - 02/10/21 MAR, and the progress notes for Resident 10 were reviewed and identified the following:

Resident 10 had a physician's order, dated 02/05/22, to hold Eliquis and aspirin until 02/06/22 due to fall with bleeding to the back of his/her head. A 02/07/22 progress note documented the medications had not been held.

In an interview with Staff 2 (Resident Care Manager) on 02/11/22 at 12:00 pm, she verified the medications had not been held and the pharmacy had not received the "hold" order.

Staff 2 stated s/he believed the pharmacy had to provide a "hold" order for the prescription in order for staff to "hold" it.  

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 and Staff 15 (RN) on 02/11/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#'s 6, 9, and 10) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in January 2021, with diagnoses including chronic kidney disease, peripheral vascular disease and hypotension. The resident was admitted to the hospital from 01/22/22 through 02/04/22.

Resident 9's signed physician orders, dated 02/04/22, and 02/01/22 through 02/10/22 MAR reviewed during the survey revealed the following:

The following medications were not added to the 02/2022 MAR when the resident returned to the facility on 02/04/22 and were not administered to the resident from 02/04/22-02/06/22 without documentation of why the medications had not been administered or having a signed physician order to discontinue:

* Ferrous Sulfate (iron supplement), two missed doses;

* Fludrocortisone (used to promote sodium retention by the kidney), two missed doses; and

* Midodrine (for low blood pressure), seven missed doses.

On 02/11/22, the need to ensure medications were administered per physician orders was discussed with Staff 1 (Administrator), Staff 15 (RN) and Staff 2 (Resident Care Manager). They acknowledged the findings.

2.  Resident 6 was admitted to the facility in 2015 with diagnoses including end stage renal disease and hypertension.

Review of Resident 6's 01/01/22 through 02/10/22 MARs and current medication orders revealed:

* A 12/29/21 physician's order for Metoprolol 50 mg was to be administered twice daily for blood pressure control. The order instructed staff to hold the morning dose on dialysis days; and

* The January and February MARs showed between 01/14/22 and 02/10/22, the resident did not receive the evening dose of Metoprolol on 11 occassions. The MAR was marked as "out of facility".

During an interview on 02/11/22 at 10:30 am, Resident 6 stated he/she routinely returns to the facility from dialysis at about 9:00 PM. Resident 6 stated staff do not offer the medication when s/he returns from dialysis and stated "I should probably be taking that". This was discussed with Staff 15 (RN) on 02/15/22 and the facility will follow up with the physician and modify the administration time as needed.

The need to ensure physician's orders were followed and medications were administered according to the resident's schedule were reviewed with Staff 1 (Administrator) and Staff 15. They acknowledged the findings.  

1. Residents #'s 6, 9, and 10 physician orders reviewed for MAR accuracy. Consultant RN will review medication services and advise necessary changes to systems.

2. Systems to be implemented as advised by consultant RN. A staff member will be trained and designated as med tech trainer to ensure all med techs are trained according to systems and regulation.

3. this will be reviewed monthly in quality assurance meetings.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 2 sampled residents (#12) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 09/2021 with diagnoses including Type 2 Diabetes.

There was no documented evidence Resident 12's signed physician orders were available in the resident's chart.

The need to ensure signed physician orders were accessible in the residents chart was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

SYSTEMS TREATMENT ORDERS

1. Current 90 day physician orders were in facility possession at time of survey, these have since been filed in the chart.

2. Systems to be implemented as advised by consultant nurse.

*complete 3 way chart audit before sending orders out.

*nurse to review and sign when orders are returned to complete physican order

*place returned orders in residents charts after triple check is completed with nurse signuture and faxed to pharmacy.

3. Quarterly physician orders have been scheduled to obtain and RCC trained on how to obtain.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented refusals. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in July 2020. September 1 through 14, 2021 MAR and TAR was reviewed and revealed the resident had 47 refusals of medications and treatments between 9/1/21 and 9/11/21.

An interview with Staff 2 (Resident Care Manager) on 9/15/21 at approximately 3:00 pm confirmed the physician had not been notified of the refusals to consent to the orders.

The need to ensure the facility notify the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 during the survey. They acknowledged the findings.

2. Resident 3 was admitted to the facility in October 2020. September 1 through 14, 2021 MAR and TAR was reviewed and revealed the resident refused Diclofenac gel on 9/12/21.

On 9/15/21 at 2:11 pm, Staff 2 (Resident Care Manager) confirmed the physician had not been notified of the refusal.

The need to ensure the facility notify the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator) and Staff 2 during the survey. They acknowledged the findings.

3.  Resident 2 was admitted to the facility in 2018 with diagnoses including asthma, osteoporosis and major depressive disorder.

Resident 2's 9/1/21 through 9/13/19 MARs were reviewed during the survey. Staff documented the resident refused the following medications:

* Divalproex (depression);

* Oyst-Cal+ D (supplement);

* Montelukast (asthma); and

* Rivastigmine (dementia).

There was no documented evidence the facility notified the physician when the resident refused to consent to the orders.

In a 9/15/21 interview with Staff 2 (Resident Care Manager), she confirmed the refusals were not reported to the physician.

On 9/16/21 the refusals were reviewed with Staff 1 (Administrator) and Staff 2. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems:

Resident Right to Refuse

1. Residents 1, 2 and 3 MAR have been reviewed for refusals and prescribers have been informed of these refusals.

2. All resident refusals will be audited and prescriber to be contacted for residents with frequent refusals to indicate their preference of notification frequency.

3. Refusals will be monitored at clinical meeting.

4, Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 2 of 3 sampled residents (#s 6 and 8) who had documented refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in February 2019. Review of the 02/01/22 through 02/10/22 MAR/TAR revealed the following:

Resident 8 refused prescribed Nystatin Powder on 02/07/22 and 02/08/22.  

On 02/11/22, Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) confirmed the physician had not been notified of the refusals to consent to the order.

The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 1, Staff  2 and Staff 15 on 02/11/22. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 2015. Review of the 01/01/22 through 02/10/22 MAR/TAR revealed the following:

Resident 6 had multiple refusals of the following medications:

* Sevelamer Carbonate (for phosporous regulation);

* Veltassa (for potassium regulation); and

* Acetaminophen (for chronic pain).

The clinical record lacked documented evidence the prescriber had been informed of the resident's refusals.

The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 2 (Resident Care Manager) on 02/15/22. No additional information was provided.

1. Consultant RN will review systems, MAR to be reviewed for refusals and proper notification will be made to prescribers as necessary.

2. All resident prescribers will be asked to advise their preference of notification frequency for refusals.

3. Refusals will be monitored monthly at quality assurance meeting.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#12) who had documented refusals. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 was admitted to the facility in 9/2021.

A review of the 08/01/22 through 08/29/22 MAR/TAR and Resident 12's weight records revealed the following  medications and treatments were refused:  

* Weekly weights on four occasions;

* Polyethylene Glycol Powder on eight occasions;

* Novolin insulin on one occasion; and

* Senna on two occasions.  

The facility failed to ensure the physician was notified when Resident 12 refused consent to the above orders and failed to ensure subsequent refusals to consent to an order were reported as requested by the prescriber.

The need to ensure the facility notified the physician when a resident refuses to consent to orders was discussed with Staff 1 (Administrator), Staff  10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

RESIDENT RIGHT TO REFUSE

1. Facility provided notification to Resident 12's pcp of refused medication.

2. Refused medications will be communicated as advised by prescriber.  Med Tech training has been completed to go instruct what "when to notify providers" means and how to complete request by providers.  

3. Refusals will be monitored weekly at clinical meeting.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

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

Resident 4's 9/1/21 through 9/14/21 MARs were reviewed and identified the following:

The MAR directed staff to document the resident's blood sugar level prior to administering insulin injections three times daily, but the MAR revealed staff documented dose of insulin, not the resident's blood sugar level.

On 9/16/21, the need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager). They acknowledged the findings.

4. Resident 1 was admitted to the facility in July 2020. The resident's September 1 through 14, 2021 MAR and TAR were reviewed and revealed the following inaccuracies:

* Eight medications lacked a reason for use;

* There were 23 blanks on the MAR with no information regarding if the medication was administered; and

* PRN medications for diarrhea, nausea and constipation lacked clear instruction for unlicensed staff regarding when and how much of the medication to administer.

The need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

5. Resident 3 was admitted to the facility in October 2020. The resident's September 1 through 14, 2021 MAR and TAR was reviewed and revealed the following inaccuracies:

* Multiple blanks on 9/13/21 with no documentation as if the medication was administered;

* Medications lacking reason for use;

* PRN Bisacodyl (used for constipation) entered three times with the same direction to staff; and

* Lacking documentation if a PRN bowel medication was effective.

The need to ensure accurate documentation of the MAR was discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility in July 2018. The resident's 9/1/21 through 9/13/21 MARs were reviewed and revealed the following:

* Two PRN pain medications without clear instructions to staff which medication to attempt first;

* Two PRN bowel medications for constipation without clear instructions to staff on which to administer first; and

* An order for a PRN nasal spray for allergies lacked clear instruction of when to administer one spray verses two sprays and lacked information regarding the resident's ability to self-direct the medication.

The need to provide resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff  2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

3. Resident 5 was admitted to the facility in August 2021. The resident's 9/1/21 through 9/13/21 MAR was reviewed and revealed multiple medications lacked a reason for use.

The need to include reasons for use in the medication record for each medication the facility administers was reviewed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21. They acknowledged the findings.

OAR 411-054-0055 (2) Systems:

Medication Administration

1. Parameters have been implemented on MAR.

2. All PRN medications to be reviewed and PRN parameters were established as needed.

3. PRN medication parameters will be reviewed with all new orders at clinical meetings daily.

4. Administrator or designee to monitor

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 3 of 4 sampled residents (#s 6, 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in January 2021 with diagnoses including chronic kidney disease, peripheral vascular disease and hypotension.

a. Resident 9's 02/01/22 through 02/10/22 MAR identified the following medications lacked reasons for use:

* Ferrous Sulfate (iron supplement);

* Fludrocortisone (used to promote sodium retention by the kidney);

* Midodrine (for low blood pressure); and

* PRN Tylenol (for pain).

b. Resident 9's signed physician orders dated 01/04/22 and January 2022 MAR, reviewed during the survey revealed the following:

The January 2022 MAR lacked specific medication administration times for the following medications:

* Allopurinol (for gout), daily 8:00 am-10:00 am;

* Atrovastatin (for high cholesterol), daily 8:00 am-10:00 am;

* Ferrous Gluc tablet (for iron supplement), daily 8:00 am-10:00 am; and

* Midodrine (for low blood pressure), 8:00 am-10:00 am, 10:00 am-12:00 pm, and 2:00 pm.

On 02/11/22, the findings were reviewed with Staff 1 (Administrator) and Staff 15 (RN). They acknowledged the findings.

3. Resident 10's 01/01/22 through 02/10/22 MAR was reviewed and revealed the following:

* Resident 10's MAR revealed multiple blanks for eight routinely scheduled medications; and

* There were no clear PRN parameters or instruction to staff regarding multiple PRN prescriptions for nausea and/or vomiting, or upset stomach.

In an interview with Staff 15 (RN) at 12:00 pm on 02/11/22, she acknowledged the blanks on the MAR and lack of PRN parameters.

The need to ensure an accurate MAR must be kept of all medications, including date and time given and clear instruction to staff, was reviewed with Staff 1 (Administrator) and Staff 15 on 02/11/22. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 2015 with diagnoses including end stage renal disease and hypertension.

Resident 6's 01/01/22 through 02/10/22 MARs identified the following:

a. Multiple time sensitive medications, including Clopidogrel (for blood thickness), Fluoxetine (for depression) and Lantus Solostar (for diabetes), had a range of times listed on the MAR for administration. The MAR did not instruct Med Tech's on specific times to administer the medications.

b. Multiple routine medications, including Acetaminophen (for chronic pain), Lantus (for diabetes) and Metoprolol (for blood pressure), had blanks on the MAR. Staff 1 (Administrator) stated there were internet connectivity issues in the facility that were contributing to the missed documentation.

c. A 12/29/21 physician's order for Veltassa was to be administered once daily on Saturdays and Sundays for potassium control; and

* The January and February MARs showed between 01/14/22 and 02/10/22, the resident refused the medication four times and received the medication four times.

During an interview on 02/11/22 at 10:30 am, Resident 6 stated his/her understanding was that s/he was supposed to take Veltassa on "non-dialysis" days. Since the resident was currently going to dialysis on Saturdays, s/he would refuse the medication on Saturdays. This was discussed with Staff 15 (RN) on 02/15/22 and the facility will follow up with the physician to get the order changed.

d. The 12/29/21 physician's order for Veltassa included parameters to "separate dose by 3 hours before and 3 hours after any other medications taken by mouth". The parameters had not been included on the MAR.

On 02/15/22, the need to ensure acurate MARs, including provisions for clear instructions for unlicensed staff, was reviewed with Staff 1 (Administrator) and Staff 15. They acknowledged the findings.

1. Consultant RN to review and provide recommendation for medication systems. Parameters have been implemented on MAR.

2. All PRN medications to be reviewed and PRN parameters were established as needed.

3. PRN medication parameters will be reviewed with all new orders at clinical meetings daily.

4. Administrator or designee to monitor

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, provided resident-specific parameters and staff instruction for 1 of 2 sampled residents (#12) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 12 was admitted to the facility in 09/2021 with diagnoses including Type 2 Diabetes.

a. Resident 12's 08/01/22 through 08/31/22 MAR identified the following medications lacked parameters for when to hold the medications and medication specific instructions for who to report to:

* Novolin flexpen, 30 units once daily in the am; and

* Novolin flex pen, 15 units once daily in the pm.

b. On 08/09/22 Penicillin, Atorvastatin and Senna lacked initials for administration or a reason why the medication was not administered.

c. On 08/10/22 CBG value was not recorded on the MAR.

The need to ensure the facility had a system in place to ensure accurate MAR/TARs were kept was discussed with Staff 1 (Administrator), Staff 10 (RCC) and Staff 27 ( LPN Consultant) on 08/31/22. They acknowledged the findings.

MEDICATION ADMINISTRATION

1) RN has added parameters for resident 12 insulin.

2) RN or PCP will advise parameters for all insulin administration and instruction.

3) This will be monitored as needed with new insulin orders.

4) Clinical Team (RN, RCC, Administrator)

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer a specific medication and failed to obtain a physician's order to self-administer a specific medication for 1 of 1 sampled resident (#1) who self-administered medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in July 2020.

On 9/15/21 at 11:32 am, Resident 1 confirmed s/he self administered the following medications:

* Basaglar Kwikpen (insulin for diabetes);

* Novolog (insulin for diabetes); and

* Flovent (inhaler for asthma).

On 9/14/21 physician's orders and an evaluation of the resident's ability to safely administer the three medications were requested.

During an interview with Staff 3 (RN) on 9/15/21 at 2:11 pm, she reported Resident 1 only self administered his/her insulin, even though there was a signed physician's order stating the resident could self administer his/her Flovent inhaler in the resident's record.

There was no documented evidence the facility evaluated Resident 1's ability to safely self-administer the Flovent.

There was no documented evidence the physician signed an order for the resident to self administer the Basaglar Kwikpen injection.

The need to complete evaluations of a resident's ability to self administer medications and to obtain signed physician orders were discussed with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) during the survey. They acknowledged the findings.

OAR 411-054-0055 (5) Systems:

Self-Administration of Meds

1. Resident 1 has been evaluated for self administration of all medications and treatments of which have been indicated by the provider okay to self administer.

2. RN hours have been increased in the community to meet community need for RN hours. RN to attend role of RN class.

3. This will be evaluated quarterly and as needed.\

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#10) who was prescribed a PRN medication to address behaviors. Findings include, but are not limited to:

Resident 10 was admitted to the facility in October 2020.

Review of the resident's 01/14/22 through 02/10/22 MARs and progress notes and 10/19/21 hospice orders showed the following:

* Lorazepam 2MG/ML, give 0.25ML/0.5MG by mouth every four hours as needed for agitation, anxiety and nausea.

The lorazepam was administered once on 01/31/22 and 02/01/22.  

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Administrator), Staff 2 (Resident Care Manager) and Staff 15 (RN) on 02/11/22. The staff acknowledged the findings.

1. Consultant RN to review systems and provide recommendations to implement. MARs reviewed, parameters put into place for all residents on psychotropic meds.

2. All psychotropic medications will be reviewed quarterly and resident specific interventions to verify parameters are implemented.

3. This will be reviewed monthly at quality assurance meeting.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (# 7) completed all required pre-service orientation. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (Resident Care Manager) on 9/15/21. The following was identified:

Staff 7 (MT/CG) was hired 8/14/21 and did not complete pre-service orientation training on the following topics:

* Resident rights and values of CBC care;

* Abuse reporting requirements; and

* Standard precautions for infection control.

The need to ensure newly-hired direct care staff completed pre-service training prior to working independently was reviewed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts

and Training: Caregiver Rqmts

1. All employee files will be audited and training requirements will be in place by date of alleged complaince.

2. All new hire staff will receive check off list with all training requirements and this will be monitored. RCC will be educqated on training requirements by date of alleged compliance. & Tracking system for annual in-service hours will be established by date of alleged compliance.

3. Audit of employee files will be completed by date of alleged compliance and as needed.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 6, 7, 8 and 9) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 9/15/21 indicated the following:

1. Staff 6 (MT), hired 8/14/21, lacked documented evidence of competency completed within the first 30 days of hire for:

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

* Providing assistance with ADL's;

* Changes associated with normal aging;

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

* General food safety, serving and sanitation;

* Perform the duties of a medication technician; and

* Abdominal Thrust training.

2. Staff 7 (MT/CG), hired 8/14/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of :

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

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's condition;

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

* General food safety, serving and sanitation; and

* First Aid and Abdominal Thrust training.

3. Staff 8 (CG), hired 8/5/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of:

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

* Providing assistance with ADL's;

* Changes associated with normal aging; and

* General food safety, serving and sanitation.

4. Staff 12 (MT), hired 8/4/21, lacked documented evidence of competency completed within the first 30 days of hire for:

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

* Changes associated with normal aging;

* Identification of changes in the resident's condition; and

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

During an interview with Staff 1 (Administrator) and Staff 2 (Resident Care Manager) on 9/16/21, the surveyor requested that Staff 6 (MT) not administer medication to residents until competency of ability to safely carry out the duties of a medication technician had been determined. Staff 1 and Staff 2 acknowledged the findings.

The need to document demonstrated competency in job duties and complete First Aid and Abdominal thrust training within 30-days of hire was discussed with Staff 1 and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (5)(8) Training within

30 days: Direct Care Staff

1. Employee files will be audited to ensure required training components are completed. RCC will be educated on these requirements.

2. Check off lists for each direct care staff will be implemented to identify trainings needed and will be monitored and reviewed as needed to ensure compliance.

3. This will be audited for compliance and reviewed as needed for newly hired direct care staff.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 18 and 20) had documented demonstration of competency in all required areas and First Aid and abdominal thrust training within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 02/10/22 indicated the following:

1. Staff 18 (MT), hired 12/30/21, lacked documented evidence of competency completed within the first 30 days of hire for:

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

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's condition;

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

* General food safety, serving and sanitation; and

* Abdominal Thrust training.

2. Staff 20 (MT), hired 12/13/21, lacked documented evidence of competency completed within the first 30 days of hire in the areas of

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

* Providing assistance with ADL's;

* Changes associated with normal aging;

* General food safety, serving and sanitation; and

* First Aid and Abdominal Thrust training.

During an interview with Staff 2, s/he stated that Staff 18 had completed the competency check list but was unable to locate the documentation.

The need to document demonstrated competency in job duties and complete First Aid and Abdominal thrust training within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 2 on 02/11/22. They acknowledged the findings. Staff 2 stated Staff 18 and 20 were scheduled to complete First aid and Abdominal thrust by 02/15/22 or before they returned to their job duties.

1. Employee files will be audited to ensure required training components are completed. RCC will be educated on these requirements.

2. Check off lists for each direct care staff will be implemented to identify trainings needed and will be monitored and reviewed as needed to ensure compliance.

3. This will be audited for compliance and reviewed as needed for newly hired direct care staff.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 29, 30, and 31) had documented demonstration of competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

A review of the facility's training records on 08/29/22 indicated the following:

Staff 29 (CG), hired 07/06/22, Staff 30 (CG), hired 07/18/22, and Staff 31 (CG), hired on 07/14/22, lacked documented evidence of competency demonstrated within the first 30-days of hire in the following training areas:

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

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification of changes in the resident's condition;

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

* General food safety, serving and sanitation.

During an interview on 08/30/22, Staff 1 (Administrator) reported training had been completed however, the facility was unable to locate the documentation.

The need to document demonstrated competency in job duties within 30-days of hire was discussed with Staff 1, Staff 10 (RCC) and Staff 27 (LPN Consultant) on 08/31/22. They acknowledged the findings.

TRAINING 30 DAYS DIRECT CARE STAFF

1) All required pieces of documentation have been received by staff 29, 30 and 31.

2) Training files will be audited to ensure required elements are in place. Training Matrix in place.

3) Upon hire and quarterly. Community will matrix to help with training system.

4) Administrator or designee.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#11) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed with Staff 2 (Resident Care Manager) on 9/15/21. Staff 11 (MT/CG) was hired 11/9/17. Annual training records, provided through online training courses and monthly staff meetings, between 11/9/2019 and 11/9/2020 were reviewed.   

The records indicated Staff 11 did not complete any in-service training on topics related to the provision of care for persons in a community-based care setting or training related to dementia.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (Administrator) and Staff 2 on 9/16/21. They acknowledged the findings.

OAR 411-054-0070 (6-7) Annual Training

and Other Requirements

1. staff 11 training file audited and needed trainings identified (see c370 & c372) staff meetings will be held monthly and include in-service trainings or requirement to complete individual department approved training modules.

2. Attendance in staff meetings will be documented at each meeting.

3. This will be evaluated at least monthly and audited to ensure staff receive training.

4. Administrator or designee to monitor.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 3 long-term staff (#16) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed with Staff 2 (Resident Care Manager) on 02/11/22. Staff 16 (CG) was hired 09/14/2020. Annual training records, provided through online training courses and monthly staff meetings, between 09/14/2019 and 09/14/2020 were reviewed. Staff 16 had no annual staff training completed for 2021 or 2022.

The records indicated Staff 16 did not complete any in-service training on topics related to the provision of care for persons in a community-based care setting or training related to dementia.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (Administrator) and Staff 2 on 02/11/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

During the entrance conference on 9/14/21, the surveyor requested Fire and life safety training records for February 2021 through August 2021. There was no documented evidence of the following areas:

* Fire drills conducted every other month consistently;

* Evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;

* Date and time of fire drill;

* Location of simulated fire origin;

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* Staff members on duty and participating; and

* Evidence of the number of occupants who were evacuated.

On 9/15/21 the above areas were reviewed with Staff 1 (Administrator). No further information was received.

OAR 411-054-0090 (1)(a-d) Fire and Life

Safety: Drills and Instruction

Refer to C422

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

During the entrance conference on 9/14/21, the surveyor requested Fire and life safety training records for February 2021 through August 2021. The following were identified:

* No documentation of alternate escape routes used during fire drills; and

* No documentation of fire and life safety training for residents upon admission and at least annually that included general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire; and

* A written record of fire safety training, including content of the training sessions and the residents attending.

The need to ensure all general fire and life safety requirements were discussed with Staff 1 (Administrator) on 9/15/21. No further information was received.

OAR 411-054-0090 (1(e-h))-(2-5) Fire

and Life Safety: General

1. Fire drill system has been reviewed and implemented by administrator and maintenance director.

2. Administrator will work with maintenance director to schedule fire drills to take place at least every other month and fire drill training to take place at least every other opposite month. Fire drill form updated to include all required elements of fire drill competency.

3. This will be monitored monthly

4. Administrator to monitor.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. This is a repeat citation. Findings include, but are not limited to:

On 02/10/22, Staff 25 (Maintenance Director) reported he was unaware of the process for instructing residents and didn't document the content of fire and life safety, at least annually, for all residents.

On 02/14/22, general fire and life safety requirements were reviewed with Staff 1 (Administrator) Staff 1 reported they didn't have a process in place that re-instructed residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.  

The need for the facility to have a system in place to ensure all residents received and documented general fire and life safety training, at least annually, was discussed with Staff 1 on 02/14/22. He acknowledged the findings.

1. Fire and life safety resident training has been reviewed by administrator and maintenance director.

2. Annual training for residents has been scheduled to train residents on fire and life safety to meet regulation of annual training.

3. This will be monitored twice per year

4. Administrator to monitor.

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

Refer to C 150, C 231, C 240, C 252, C 260, C 270, C 282, C 300, C 303, C 305, C 310,

C 372, and C 422

Refer to C 231, C 240, C 252, C

260, C 270, C 282, C 300, C 303, C 305,

C 310,

C 372, and C 422

Based on interview and record review, it was determined the facility failed to ensure their second re-visit 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 150, C 240, C 260, C 270, C 300, C 303, C 305, C 310, C 372.

NOT FOLLOWING PLAN OF CORRECTION

refer to plan of corrections for c240, c260, c270,c280, c282, c300,c303, c305, c310, c372, c455

Based on interview and record review, it was determined the facility failed to ensure their third re-visit 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 282.

C455: Cornell Estates Plan of Correction

Not following plan of correction. Please refer to plan of correction for C282

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 9/14/21 and 9/15/21, the following was observed:

* Carpet throughout the common areas and hallways had black spots, stains, blackened areas and uneven surfaces;

* Multiple baseboards throughout the facility had gouges;

* Multiple ceiling panels throughout the facility, including hallway between Room 170 and 179,  near library on the second floor and near Room 205, were stained with large brown that looked like it resulted from water leaks;

* Multiple doors including Room 162, 163, 152, 189, 191 and Tub room door had scuffs and scratches; and

* Ventilation covers and filters, near Room 181, were covered with layers of dust.

The environment was toured on 9/15/21 with Staff 1 (Administrator). He acknowledged the above areas needed to be cleaned and repaired.

OAR 411-054-0300 (4)(d-i) General

Building: Doors-Walls, Cleanable

1. Administrator and Regional Director have walked through the community to identify areas of need and are working with outside company to repair noted areas.

2. Administrator will walk through the community after renovation is completed and identify areas of need and  coordinate repairs as needed.

3. This will be evaluated at least monthly.

4. This will be monitored by administrator or designee.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 9/14/21 and was observed to have windows with sills lower than 36 inches in the resident's units and common areas on the second floor.

The window in Room 292, opened fully and had no mechanism to prevent an accidental incident.

On 9/15/21 at 10:20 am, the facility was toured with Staff 1 (Administrator) and he acknowledged windows on the second floor were not designed to prevent accidental falls.  

OAR 411-054-0300 (5) Resident Units - Windows on 2nd floor must have policy to prevent accidental falls.

1. For all windows which have sills lower then 36", removable window stoppers will be installed.

2. System will be corrected by implementing policy on windows with sills lower than 36", and adding on to our current room turn process.

3. Windows will be evaluated on an as needed and on-going basis. The need for window stoppers will be evaluated immediately and implemented as needed. This need will also be re-evaluated as part of the room turn process.

4. Administrator and Maintenance director to monitor this need.

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During the facility tour on 9/14/21, the following were observed:

* Wall-mounted heaters were in Residents' bathroom 159, 162, 289 and 292;

* The heaters were located where residents could come in incidental contact with them;

* When the heaters were turned on, the surface temperatures of the grates measured with the surveyor's thermometers ranged from 131 to 161 degrees F.; and

* None of the wall-mounted heaters were in use at the time of survey.

On 9/15/21 at 10:20 am, Staff 1 (Administrator) was informed of the increased temperature and acknowledged the need to ensure wall heater covers did not exceed 120 degrees Fahrenheit.

The need to ensure that covers, grates, or screens or wall heaters did not exceed 120 degrees Fahrenheit was discussed with Staff 1 on 9/15/21 and 9/16/21. He acknowledged the findings.

OAR 411-054-0300 (8) Heating and

Ventilation

1. Wall mounted heaters in all assisted living apartment bathrooms have been disabled to prevent future use. Temperatures of these fixtures will not exceed 120 dgerees.

2. Temperature of bathroom will not be controlled by use of wall mounted heater.

3. This will be evaluated and completed by date of alleged compliance and does not require ongoing evaluation.

4. Administrator or designee to ensure this is completed.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 9/15/21 with Staff 1 (Administrator). Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

On 9/15/21, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1.  He acknowledged the findings.

OAR 411-054-0300 (11-13) Call System - Exit doors

1. Exits requiring alarming devices have been identified and alarming devices are now in place on all exit doors

2. Staff will be notified of residents exiting the building by alarming devices on exit doors.

3. The use and activity of alarming devices on exit doors will be evaluated at least quarterly.

4. Administrator or designee to monitor