The findings of the re-licensure survey conducted 05/23/22 through 05/25/22 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 re-visit to the relicensure survey of 05/25/22, conducted 09/13/22 through 09/14/22, 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 second revisit to the re-licensure survey of 05/25/22, conducted 05/15/23 through 05/16/23, 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 and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

Observations were made in the facility during the survey to determine adherence to universal precautions for infection control.

Resident 4 was admitted to the facility in 2019 and had diagnoses which included dementia.  

Observations and interviews with staff during the survey revealed s/he had an indwelling Foley catheter. S/he relied on staff for catheter care needs.

On 09/14/22 at 9:10 am, the surveyor and Staff 2 (RN) observed Resident 4 sitting in a recliner in a common hallway. The catheter urine bag was lying on the floor. There was no barrier between the bag and the floor to prevent cross contamination. Staff 2 stated staff should not have placed the catheter bag onto the floor.

The above observation was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) during the exit interview on 09/14/22. They acknowledged appropriate infection control practices were not implemented. No further information was provided.

We will continue training staff on infection control, including catheter care. Catheter care is being put into the serivce plans with directions on how to care for a catheter it will also be put in point of care for charting on the catheter. The RN will be responsible in ensuring this is done. This area will be monitored daily to ensure that infection control and catheter care is being followed. The RN, RCC, and Administrator will be responsible to see that the corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure 1 of 1 sampled resident (#4) was treated with dignity and respect. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 2019 and had diagnoses which included dementia.  

Observations and interviews with staff during the survey revealed s/he had an indwelling Foley catheter. S/he relied on staff for catheter care needs.

Resident 4 was observed on 09/13/22 at 11:50 am, sitting in a recliner in a common hallway near his/her apartment. The catheter bag was in a plastic bin on the floor. The bag was uncovered and urine was visible.

At the breakfast meal on 09/14/22, staff attached the uncovered catheter bag to the bottom of the resident's wheelchair. The uncovered bag was visible to other residents, resulting in an undignified dining experience.

On 09/14/22 at 9:10 am, the surveyor and Staff 2 (RN) observed Resident 4 sitting in a recliner in a common hallway. The catheter urine bag was lying on the floor, uncovered, and urine was visible. Staff 2 acknowledged the catheter bag should have been covered.

Failure to provide dignity in common areas and in the dining room was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 (RCC) during the exit interview on 09/14/22. All agreed the catheter bag should have been covered. They acknowledged the findings.

All staff will be informed of the resident rights including the right to dignity. Aids will make sure all catheters are in a bag and if placed on the floor it will be in a bag and in a basin for infection control. Catheter care is being put into the point of care charting system as a reminder to staff and for holding them accountable that proper care for the catheters are being followed to allow for dignity for the residents. This will be evaluated daily. The med aids, RN, RCC and the Administrator will be responisible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations contained all required components, failed to ensure a 30-day update evaluation was completed and included documentation of who was involved in the process for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 04/2022 with diagnoses including diabetes, end stage renal disease, and sleep apnea.

a. Resident 3's move-in evaluation, dated 04/15/22, lacked documentation relating to the following required elements:  

* Customary routines, including sleeping and bathing;  

* List of medications and PRNs used;

* Mental health issues including history of treatment and effective non-drug interventions;

* Personality, including how the person copes with change or challenging situations;

* Complex medication regimen;

* Recent losses; and

* Environmental factors that impact the resident's behavior.

b. There was no documented evidence a 30-day evaluation update was completed.

c. The move-in evaluation lacked documentation of who was involved in the process.

The need to ensure all required components were included in the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22 at 10:45 am. They acknowledged the findings.

A new move in evaluation form was created that covers all necessary components. When we go to assess a potential new resident there will at the very least be the RN and the Administrator that will go. Signature lines were added to the evaluation form to show who was present. The computer system PCC is now set up so that we can set it to alert us when the 30 days and the quarterlies are due. We are putting a triple check system in place that every month the RN, the assistant administrator, the administrator and medical records will do an audit to make sure that all assessments are done on time. The RN, Administrator and Assistant Administrator will be responsible to see that all the corrections are complete and monitored monthly to insure that the rule is met.

Based on observation, interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements, and failed to ensure evaluations were reviewed and updated when a resident experienced a significant change of condition for 2 of 2 sampled residents (#s 4 and 5) whose most recent evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2019.

During the entrance conference on 09/13/22, staff reported the resident had a recent significant decline in health, a recent fractured sacrum, and was admitted to hospice in 09/2022.

Interviews with care staff and observations of Resident 4 during the survey revealed s/he received full assistance with ADL care needs and had a catheter.

Resident 4's evaluation, dated 08/31/22, revealed it had not been updated to reflect the resident's significant changes in condition and was not reflective of his/her needs in the following areas:

* Siderail use;

* Vision - assistive devices;

* Housework and laundry;

* Mobility and assistive devices;

* Bathing;

* Dressing;

* Activities; and

* Wandering.

The need to ensure the evaluation was updated with significant changes in condition and was reflective of Resident 4's current care needs was discussed with Staff 1 (Administrator) and Staff 2 (RN) during interviews on 09/14/22. They acknowledged the findings. No further information was provided.

2. Resident 5 moved into the facility on 07/15/22.

The new move-in evaluation failed to address the following elements:

* Customary routines: sleeping, eating and bathing;

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Personality: including how the person coped with change or challenging situations;

* Dental status;

* Ability to use call system;

* Pharmaceutical and non-pharmaceutical pain interventions, including how a person expressed pain or discomfort;

* Nutritional habits and fluid preferences;

* List of treatments: type, frequency and level of assistance needed;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Emergency evacuation ability;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Smoking, ability to smoke safely;  

* Alcohol and drug use; and

* Environmental factors that impact behavior including, but not limited to noise, lighting, and room temperature.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 09/14/22 at 12:00 pm. They acknowledged the findings. No further information was provided.

A new move-in intake evaluation form has been created to include all the required elements. The new form can also be used for change of condition. To start documentation and monitoring change of conditions a check list is also on the new form as a reminder to change and update the service plans as needed. This will be evaluated weekly. The RN, RCC, and the Administrator will be responsible to see that the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were followed, reflective of residents' needs, and provided clear direction to staff for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021.

Observations and interviews with Resident 1 during the survey, and review of the clinical record including the service plan, dated 04/05/22, revealed the service plan was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Specific ADL care needs;

* Bathing assistance provided by hospice;

* Oxygen flow rate;

* Sleeping in recliner;

* Housekeeping and laundry services;

* Activity preferences;

* Commode use;

* Weight fluctuations; and

* Decreased appetite.

The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22. They acknowledged the findings. No further information was provided.

2. Resident 3 was admitted to the facility in 04/2022 with diagnoses including Type 2 Diabetes, end stage renal disease, and sleep apnea.

Observations and interviews with Resident 3 during the survey and review of Resident 3's most current service plan, dated 04/15/22, revealed it was not reflective of the resident's care needs and lacked clear direction in the delivery of services in the following areas:

* Making the bed and housekeeping;

* ADL's including toileting, dressing and transferring;

* Behaviors;

* Social, leisure activities;

* Inaccurate instructions regarding suctioning; and

* Oxygen flow rate.

The need to ensure service plans were accurate, reflective, and provided clear direction to staff was discussed with Staff 1 (Administrator) and  Staff 3 (Administrative Assistant) on 05/25/22 at 10:45 am. They acknowledged the findings.

The actions that we are taking to get this rule corrected are now bringing in floor staff when doing care conferences to make sure that we have accurate care needs in place to correctly care for the residents. Making sure that the change of conditions are put into the service plan and followed accordingly. We are putting this new system in place so that every resident will be looked at closely, quarterly,  and as needed for change of conditions. Bringing the floor staff in that takes care of the residents on a daily basis will give us a better view of the real care that the residents need. The area needing correction will be evaluated monthly. The RN, Administrator and the Assistant Administrator will be responsible in seeing that the correction are complete and being monitored.   

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 regarding the delivery of services, or were reviewed and updated as appropriate within the first 30-days of move-in for 2 of 2 sampled residents (#s 4 and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2019.

Interviews with care staff, observations and an interview with Resident 4, review of the clinical record, and current service plan dated 08/31/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Hospital bed;

* Siderail use;

* Housekeeping services;

* Laundry services;

* Mobility;

* Bathing assistance;

* Dressing assistance;

* Activities;

* Wandering interventions;

* Wander Guard;

* Care of indwelling catheter; and

* Care provided by hospice.

The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) during interviews on 09/14/22. They acknowledged the findings. No further information was provided.

2. Resident 5 was admitted to the facility on 07/15/22.

Observations and an interview with Resident 5, review of the clinical record, and service plan dated 07/13/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Use of incontinence products;

* Care of dog;

* Skin breakdown;

* Home Health;

* Laundry services;

* Bed mobility;

* Personal hygiene and oral care;

* Compression stockings;

* Use of wheelchair and staff assistance; and

* Use of a walker.

Additionally, the service plan had not been reviewed and/or updated since 07/13/22 (initial service plan).

The need to ensure the service plan was reflective of Resident 5's current care needs, provided clear direction to staff, and was reviewed and updated as appropriate within the first 30-days of move-in was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 09/14/22 at 12:00 pm. They acknowledged the findings. No further information was provided.

The action we are taking to get this rule corrected are a service plan team has been created to meet monthly to go over service plans for the residents before their quarterly assessments . The service planning team will go over the resident ensuring that the service plan reflects the cares that the staff are providing. Making corrections and changes as needed. The area needing correction will be evaluated monthly. The RN, RCC, and Administrator will be responsible in seeing that the correction are complete and being monitored.  

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 3 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:

Residents 1 and 3's current service plans were reviewed during the survey.

The service plans for Residents' 1 and 3 lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22. They acknowledged the findings.

We have created a service planning team that will meet monthly to go over resident care, we will then have the care conference with the resident, a family member, a caregiver, the RN,  and the Administrator. After the care conference is complete, we will send the notes to the residents physician to ensure that they agree with the plan of care. We now have a system in place so this rule violation will not happen again. This area of correction will be evaluated monthly. The Administrator, Assistant Administrator and the RN will be responisible in seeing that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 2 of 2 sampled residents (#s 4 and 5). This is a repeat citation. Findings include, but are not limited to:

Resident 4 and 5's current service plans were reviewed during the survey.

The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 09/13/22 at 1:00 pm. They acknowledged the findings.

The action we are taking to get this rule corrected are a service plan team has been created to meet monthly to go over service plans for the residents before their quarterly assessments . The service planning team will go over the resident ensuring that the service plan reflects the cares that the staff are providing. Making corrections and changes as needed. The area needing correction will be evaluated monthly. The RN, RCC, and Administrator will be responsible in seeing that the correction are complete and being monitored.  

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and determine if fall interventions were implemented, effective or if new interventions were needed for 1 of 2 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted in 2021, was on hospice services, and had a history of falls.

Resident 1's clinical record and charting notes, reviewed from 02/01/22 through 05/23/22, revealed the following:

a. Resident 1 was admitted to the hospital on 01/27/22 and returned to the facility on 02/09/22. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

b. The resident fell on 03/15/22, 03/27/22 and 04/14/22. Review of the record revealed no documented evidence the facility monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently determine if service-planned interventions were implemented, were effective, or if new interventions were needed.

Additional information was requested on 05/24/22.

On 05/25/22, Staff 1 (Administrator) and Staff 3 (Administrative Assistant) reported they reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved, and the facility failed to determine if service-planned interventions for falls were implemented, were effective, or if new interventions were needed. No further information was provided.

We are educating our staff on the different changes of condition, whether it is short term or long term. The RN will make the necessary assessment, and documentation, and place the resident on alert charting for the staff to continue monitoring the changes, until it is resolved or is determined to be a long term change of condition. We will be watching the resident to determine if any interventions are needed to be implemented and if they are effective, or if we need to find new interventions. The nurse will assess and document on any change of condition. We will be evaluating the correction monthly. The RN will be responsible in seeing that the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, determine if fall interventions were implemented, effective or if new interventions were needed, and failed to ensure significant changes of condition were evaluated and service plans updated for 2 of 2 sampled residents (#s 4 and 5). This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted in 2019 and had diagnoses which included a recent sacrum fracture and admit to hospice.

Resident 4's clinical record and charting notes, reviewed from 07/24/22 (AOC date) through 09/13/22, revealed the following:

a. Resident 4 fell on 08/23/22 and 09/10/22. The facility failed to investigate the circumstances for the falls to determine if service-planned interventions were implemented, were effective, or if new interventions were needed. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the fall on 08/23/22 until resolved.

b. Resident 4 fell on 08/23/22 and was subsequently diagnosed with a sacral fracture on 09/02/22. The facility failed to evaluate the significant change and update the service plan to reflect the changes in care needs.

c. On 09/07/22, the resident was admitted to hospice services and had an indwelling catheter inserted. Although the service plan indicated the changes in condition, it was not updated to reflect specific care interventions.

The need to ensure the facility monitored and documented on the progress of short-term changes in condition at least weekly until resolved, determine if fall interventions were implemented, effective or if new interventions were needed, and ensure significant changes of condition were evaluated and the service plan updated was shared with Staff 1 (Administrator) and Staff 2 (RN) on 09/14/22. They acknowledged the findings. No new information was provided.

2. Resident 5 was admitted to the facility in 07/2022.

Resident 5's clinical record and progress notes, reviewed from 08/01/22 through 09/13/22, revealed the following:

a. Resident 5 returned to the facility on 08/04/22 after surgery and a rehabilitation recovery stay. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

b. The resident fell on 08/04/22, 08/12/22, 08/23/22, 08/28/22 and 09/01/22. Review of the record revealed no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved. Additionally, the facility failed to consistently evaluate if service-planned interventions were implemented, were effective, or if new interventions were needed.

c. On 08/23/22, Resident 5 complained of a sore throat. Although alert monitoring was initiated, there was no documented monitoring of resident's condition until resolution.

d. Resident 5 started a new medication on 08/26/22 for redness and peeling to his/her feet. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

Additional information was requested on 09/14/22.

On 09/14/22 at 12:00 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved, and the facility failed to consistently evaluate if service-planned interventions for falls were implemented, were effective, or if new interventions were needed. No further information was provided.

We are educating our staff on the different changes of condition, whether it is short term or long term. The RN will make the necessary assessment, and documentation, and place the resident on alert charting for the staff to continue monitoring the changes, until it is resolved or is determined to be a long term change of condition. We will be watching the resident to determine if any interventions are needed to be implemented and if they are effective, or if we need to find new interventions. The RN will assess and document on any change of conditions. If the RN is out for any reason we will reach out to our skilled facility for their DNS or another RN to come do a change of condition assessment. All med aids will be instructed on how to do an incident report for falls, all falls will have incident report filled out and a change of condition if needed. Service plans will be updated with and changes an assessment will be done to put into place any interventions that may help prevent any future falls.This will be monitored weekly. The Med Aids, RN, RCC, and Administrator will be responsible to see that the corrections are completed and being monitored.  

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 1 of 1 sampled resident (#1) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 1 was admitted in 2021 with diagnoses which included congestive heart failure, atrial fibrillation and hypertension.

During the entrance conference on 05/23/22, staff reported that the resident had a recent significant decline in health and was currently on hospice services.

Review of the clinical record revealed the resident was admitted to hospice on 02/18/22 for congestive heart failure.

The decline in health and admission to hospice constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 05/24/22 at 10:45 am, Staff 2 (RN) stated he was newly hired and was unsure if the previous RN had completed an assessment. He reviewed the record and acknowledged an RN assessment had not been completed.

The RN is updating and putting the change of condition policy in place which will include any short term or long term changes. The RN will assess and document any and all changes of condtions putting the resident on alert charting for the staff to continue to monitor until the change either resolves or is determined to be a long term change of condition. This correction will be monitored monthly by the Administrator, the admin assistant and the RN.  

Based on interview and record review, it was determined the facility failed to ensure significant change of condition assessments included resident status, interventions made as a result of the assessment, and were completed timely by a facility RN for 1 of 2 sampled residents (#4) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted in 2019 with diagnoses which included dementia.

During the entrance conference on 09/13/22, staff reported the resident had a recent significant decline in health, was diagnosed on 09/02/22 with a fractured sacrum, and on 09/07/22 was admitted to hospice and had an indwelling catheter inserted.

The decline in health, fracture, admission to hospice, and new catheter constituted significant changes in condition for which timely assessments by the facility RN were required.

On 09/12/22 (several days after the significant changes occurred) Staff 2 (RN) documented in facility progress notes that the resident had a " ...sacral fracture ...transitioned to Hospice ...has an indwelling catheter to provide comfort ..." No further information, including an assessment of the resident's status and interventions made as a result of the assessment were documented.

The need to ensure documented RN assessments for significant changes in condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 09/14/22 at 9:00 am. Staff 2 explained he was on vacation when the changes in condition occurred. The findings were acknowledged. No further information was provided.

The actions we are taking to correct this rule violation is the RN is on call 24/7 when the RN goes on vacation, a RN from the skilled facility will come do a change of condition assessment, so it is done in a timely manner. When the facility RN returns he will also do his own assessment and follow up on the change of conditions and will continue to monitor until resolved. This will be monitored weekly. The RN, RCC, and Administrator will be responsible to ensure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 05/23/22, Resident 3 was identified to be administered insulin injections by non-licensed staff.

Resident 3's MARs, reviewed from 05/01/22 - 05/23/22, revealed insulin had been given by Staff 6, 8 and 10 (MTs) on multiple occasions.

Review of Resident 3's delegation documentation during the survey revealed the following:

* Delegations for Staff 6 and 8 completed by Staff 2 (RN) on 05/09/22 and 05/14/22 respectively, lacked a current nursing assessment and condition of the client; and

* There was no delegation completed for Staff 10.

In an interview on 05/25/22 at 9:00 am, Staff 2 (RN) acknowledged assessments had not been completed when staff were delegated, and he had not completed the delegation for Staff 10. Staff 2 stated Staff 6, 8 and 10 would not give insulin until the delegation had been completed.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) on 05/25/22 at 10:30 am. She acknowledged the findings.

All RN delegations will be put into place. As of 6/13/2022 all RN delegations are current. The RN will review initially at 60 days then every 180 days to be compliant with state regulation. The RN, Administrator and the Assistant Administrator will be responsible for insuring that we are in compliance with the state regulations with delagations.  

Based on observation, interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 2 of 3 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 04/2022 with diagnoses which included insulin dependent diabetes and hypertension.

Resident 3's physician orders and MARs, reviewed from 05/01/22 through 05/23/22, revealed the following orders were not followed:

a. Resident 3 had an order for Doxazosin Mesylate 1 mg twice daily for hypertension. Staff were instructed to hold the medication if the systolic BP (upper number) was less than 140. According to the MAR, staff administered the medication on 05/21/22 without obtaining the BP to determine if the medication should have been held.

b. The resident had an order for Aspart sliding scale insulin to be given three times a day in varied amounts based on results of the CBGs. On 05/01/22, the noon CBG result indicated additional sliding scale insulin should have been administered. However, none was documented as given. Additionally, on 05/02/22, no CBG was obtained to determine if sliding scale insulin was needed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22 at 10:45 am. They acknowledged the findings. No further information was provided.

2. Resident 2 was admitted to the facility in 03/2018 with diagnoses including congestive heart failure and chronic obstructive pulmonary disease.

Resident 2's 05/01/22 through 05/23/22 MARs and current physician's orders were reviewed.

a. Resident 2 had an order for oxygen to be administered at 2 liters per minute (lpm). Resident 2 was observed receiving oxygen at 3 lpm;

b. Resident 2 had a physician's order for Lasix 40 mg twice daily.

A progress note dated 05/02/22 indicted the order had been changed to once daily.  

Resident 2's MARs indicted the medication was being administered once daily starting on 05/03/22.

There was no signed physician's order for the reduced dose of Lasix. A signed order was received at the facility on 05/24/22.

The need to ensure medication orders were administered as prescribed and written orders for all medications administered were maintained was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 05/24/22. They acknowledged the findings.

As of 6/1/2022 all orders have been review by the RN they are now all correct. We have corrected the sliding scale insulin dosing per physicians orders and made sure that directions and parameters are in place for both insulin sliding scales, and blood pressure medications. Blood pressure medications  have set parameters if physician sees necessary, if so those readings will be entered into the computer prior to blood pressure medication being given. We are working on getting our charting system pointclickcare updated so when a glucouse reading is taken, the reading is then entered into the computer to show up on the MAR, and the amount of insulin to be given will also need to be entered at that time to show up on the MAR. We will be monitoring this monthly. The RN, Administrator Assistant and the Administrator will be responsble in seeing that the corrections are completed and monitored.  

2. Resident 3 was admitted in 04/2022 with diagnoses which included insulin dependent diabetes and hypertension.

Residents 3's MARs were reviewed from 05/01/22 through 05/23/22 and the following was noted:

a. Reasons for use was not indicated for all medications.

b. The MAR instructed staff to administer Latanoprost Ophthalmic every evening in the left eye for glaucoma. However, observation and interview with the resident during the survey revealed his/her left eye had been removed.

In an interview with Staff 6 and 9 (MTs) on 05/24/22 at 1:45 pm, they stated the resident received the Latanoprost in the right eye, not the left as indicated on the MAR. They acknowledged the MAR was inaccurate.

c. Resident 3 had an order for Simvastatin 20 mg once daily for hyperlipidemia. On 05/22/22, no dose was documented as administered.

On 05/24/22 at 1:45 pm, the surveyor and Staff 6 (MT) checked the MARs and medication supply. Staff 6 verified that the medication had been given, but staff failed to document.

d. The resident had an order for Aspart sliding scale insulin to be given three times a day in varied amounts based on results of the CBGs.

* The sliding scale noted on the 05/2022 MAR instructed staff to give the following:

- If the CBG was 140 - 180, give 2 units;

- If the CBG was 180 - 240, give 4 units;

- If the CBG was 240 - 300, give 6 units; and

- 10 units were to be given for CBGs above 300.

The MAR gave staff conflicting instructions on the correct units to administer if the CBG was 180 (2 units or 4 units) or 240 (4 units or 6 units).

On 05/25/22, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant). They acknowledged the findings. No further information was provided.

3. Resident 1 was admitted in 2021 and had diagnoses which included congestive heart failure, atrial fibrillation and hypertension.

Residents 1's MARs were reviewed from 05/01/22 through 05/23/22 and the following was noted:

* Reasons for use was not indicated for all medications; and

* Lack of resident-specific instructions for multiple PRN bowel and pain medications, including which one to administer first.

The need for the facility to ensure MARs were accurate was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, included reason for use, and provided clear instruction and parameters for administration of PRN medications for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 03/2018 with diagnoses including chronic pain, chronic obstructive pulmonary disease, and congestive heart failure.

Resident 2's 05/01/22 through 05/23/22 MARs and current physician's orders were reviewed and found:

* Potassium Chloride 10 meq, given once daily, lacked a reason for use;

* Hydrocodone-Acetaminophen 5-325, given every four hours, lacked a reason for use;

* Hydrocodone-Acetaminophen 5-325 was not documented as administered on the MAR for two occasions on 05/17/22. The medication was signed out on the narcotic dispensation log; and

* Routine oxygen administered at 2 liters per minute was not noted on the MAR.

The need to ensure MARs were accurate and complete was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Administrative Assistant) on 05/24/22. They acknowledged the findings.

The orders and MAR have been audited and corrected the sliding scale for the insulin and the parameters for blood pressure medication and prn medications have been established so staff know which medication to use first. We have also added the indications for what a medication is being used for. We will be doing monthly audits on the physicians orders and MARS to ensure accuracy. The RN, Administrator and the assistant administrator will be responsible for making sure it is corrected and completed and monitored to insure we stay in state compliance.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 4 and 5). This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted in 5/2019, and Resident 5 was admitted in 7/2022.

MARs for Residents 4 and 5 were reviewed from 09/01/22 through 09/13/22 and the following was noted:

* Lack of resident-specific instructions for multiple PRN bowel medications, including sequential order of use.

In an interview on 09/14/22 at 12:00 pm, Staff 2 (RN) reviewed the residents' MARs. He confirmed the multiple PRN bowel medications lacked specific instructions for staff. No further information was provided.

The rule violation will be corrected by, PRN medications will have set parameters with clear directions of which medication to give first. We have asked the physicians to add the parameters and which medication to use first to the signed physician's orders. The med aids will be documenting when the prn medication either works or does not work. This will be monitored daily. The RN, RCC, and Administrator will be responsible for ensuring that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#4) who was prescribed PRN psychoactive medication for behaviors. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 2019 and had diagnoses which included anxiety.

Resident 4 had physician's orders for Lorazepam as needed for anxiety and agitation.

Review of MARs and progress notes, from 08/01/22 - 09/13/22, revealed staff administered PRN Lorazepam on 24 occasions. There was no documented evidence staff consistently attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

During interviews on 09/14/22, Staff 10 and 15 (MTs) and Staff 3 (RCC) reviewed the record and acknowledged staff had not consistently documented non-drug interventions attempted prior to administering the Lorazepam.

The need to ensure staff documented that non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) during the exit interview. They acknowledged the findings.

This rule violation will be corrected by, the non-pharmaceutical interventions will be added to the order, stating that the non-pharmaceutical interventions must be tried first and documented that they failed before giving the psychotropic medication. This correction will be monitored daily. The RN, RCC, and Administrator  will be responsible for ensuring that this rule violation corrections have been made and monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use of and precautions for the device, and documentation of the use of the device in the resident's evaluation and service plan for 1 of 1 sampled resident (#4) who had siderails on their bed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2019.

On 09/13/22 at 11:50 am, the resident's bed was observed to have bilateral half-length siderails in the up position.

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the device in the resident's evaluation and service plan.

The above information was discussed with Staff 2 (RN) on 09/14/22 at 9:00 am. He was unaware the resident had siderails on his/her bed. He acknowledged the findings.

The actions being taken to correct this rule violation are the bed rails have been removed, the floor staff will report to the RN when any new equipment is delivered for a resident to ensure it is the correct equipment and that we have the proper orders for the equipment. This will be monitored weekly. The RN, RCC, and Administrator will be responsible for ensuring that the corrections are made and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to beginning job responsibilities for 3 of 3 newly hired staff (#s 12, 13 and 14) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 05/24/22.

1. Staff 12 (CG), hired 01/24/22, Staff 13 (CG), hired 01/11/22, and Staff 14 (CG), hired 03/08/22, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities.

2. Prior to beginning job duties, Staff 12 and 14 lacked documented evidence of completing pre-service orientation for:

* Resident rights and the values of community-based care; and

* Fire safety and emergency procedures.

3. Prior to beginning job duties, Staff 13 lacked documented evidence of completing pre-service orientation for:

* Resident rights and the values of community-based care;

* Abuse reporting requirements;

* Standard precautions for infecting control; and

* Fire safety and emergency procedures.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator), Staff 3 (Administrative Assistant), and Staff 11 (Human Resources Director) on 05/24/22. They acknowledged the findings.

As of 6/1/2022 all new employees have completed pre-service orientation. To maintain compliance a check list has been initiated to make sure new employees are ready to start work. This will be monitored by HR and the Administrator and the Assistant Administrator.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 caregiving staff (#s 12, 13 and 14) demonstrated satisfactory performance in all job duties within 30 days of hire and were trained in First Aid. Findings include, but are not limited to:

Training records were reviewed on 05/24/22.

1. There was no documented evidence Staff 12 (CG), hired 01/24/22,  Staff 13 (CG), hired 01/11/22, and Staff 14 (CG), hired 03/08/22, had demonstrated competency in all required areas within 30 days of hire including, but not limited to:

* Providing assistance with ADL's; and

* General food safety, serving and sanitation.

2. There was no documented evidence Staff 12, 13 and 14 had been trained in First Aid.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and were trained in First Aid was reviewed with Staff 1 (Administrator), Staff 3 (Administrative Assistant), and Staff 11 (Human Resources Director) on 05/24/22. They acknowledged the findings.  

As of 7/24/2022 all staff will have their pre-service dementia care training and pre-service infection control training complete. All aids will have a current first aid training completed. The staff competencies training form has been revised giving places for the trainer and the trainee to initial as the competencies are performed to the satisfaction of facility protocol. The trainer and trainee will both sign off on the 30 day competencies. This will be monitored every 30 days after a new hire has begun working. The Assistant Administrator, RN and Administrator will ensure this rule is followed per Oregon rules and regulations.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility Fire and Life Safety records from 11/01/21 to 04/30/22 were reviewed on 05/24/22. Fire and life safety records lacked documentation of the following required components:

1. The documentation lacked evidence of fire drills being conducted every other month.

2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills.

3. Fire drill records lacked documentation of the following required elements:

* The escape route used;

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

* Evidence alternate routes were used during fire drills.

The need to ensure fire drills were conducted according to the OFC and fire drill records included documentation of all required components was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant)  05/25/22 at 10:45 pm. They acknowledged the findings.

Fire drills will again be conducted on an alternating month/shift basis and on the off months ALF staff will participate in the SNF drills. This will be monitored by the Maintenance manager and the Administrator.

Based on interview and record review, it was determined the facility failed to ensure residents were provided fire and life safety training annually according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility Fire and Life Safety records from 11/01/21 to 04/30/22 were reviewed on 05/24/22. The following deficiency was identified:

The facility fire and life safety records lacked documented evidence residents were provided training and instruction on fire and life safety annually.

The need to ensure residents were instructed on fire and life safety procedures annually per the OFC code was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant ) on 05/25/22 at 10:45 am. They acknowledged the findings.

Fire and Life safety has been added to our new resident admitting packet.The maintance manager will conduct a fire and life safety training, with all new admits within the first 24 hours of move-in. A map of the facility will be given in the new admission packets as well showing the residents where their room is, and will be showing the different exit routes. The residents will take part in our annual facility evacuation drill which is scheduled for 6/29/2022. This will be monitored by the Administrator and the assistant administrator.  

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

Refer to C 252, C 260, C 262, C 270, C 280 and C 310.

The actions to correct this rule violation is to continue correcting our previous plan of correction and putting our current plan of correction in place. The system will be corrected by putting the plan of correction into action and monitoring closely to ensure all plans are followed. This will area of correction will be monitored weekly to ensure we are following the plan. This will be monitored by the RN, RCC, and Administrator.

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

The facility was toured on 05/23/22. Observations and interviews with staff during the survey confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (Administrator) and Staff 3 (Administrative Assistant) on 05/25/22 at 10:45 am. They acknowledged the findings.

As of 6/13/2022 all exit doors have been equipt with alarms that sound when a door is open. I will be requesting from my board of directors permission to integrate the doors to our call light system.