The findings of the re-licensure survey, conducted 8/16/21 to 8/18/21, 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 08/18/21, conducted 01/03/22 through 01/04/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 08/18/21, conducted 02/28/22, are documented in this report. It was determined the facility was in compliance with the the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to:

A tour of the facility conducted on 8/16/21 identified the following:

* The most recent survey was not posted and available for view; and

* The name of the administrator or designee in charge was not posted.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1(Administrator in training). She acknowledged the findings.

C 152 SS=F OAR 411-054-0025 (5) Facility Administration: Required Postings

1. Immediate actions taken to correct the ruel violation include posting the most recent survey to ensure it is available for view. The name of the administrator or designee in charge has been posted in public view. Administrator has verified that all required postings are displayed in an accessible and conspicuous location for public viewing.

2. The system will be corrected so this violation will not happen again by ensuring that the administrator is trained on the importance of accurate postings and provided with a copy of the Oregon Administrative rules and regulations for reference. This training will be part of future orientation for all department heads.

3. The area needing correction will need to be evaluated on a monthly basis as part of environmental and systems self audit.

4. The Administrator or designee will be responsible to ensure corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

1. During the survey, conducted 8/16/21 through 8/18/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility.

* The facility had not established adequate storage and disinfection practices for eye protection. Face shields and goggles were observed to be stored without measures in place to prevent contamination;

* Eye protection was not worn; and

* Facility staff were observed with face masks worn below the nose or chin on all days of the survey.  

2. Universal Workers, who provided incontinent care, were observed preparing and serving food without donning aprons.

Infection control practices were reviewed with Staff 1 (Administrator in training) and Staff 2 (RN). They acknowledged the need for increased oversight of infection control practices in the building.

C 160 SS=F OAR 411-054-0025 (4) Reasonable Precautions

1. Immediate actions taken to correct the rule violation include:

*The Community has reviewed the Oregon Department of Human Services infection control guidelines and verified that the following actions have taken place to protect the facility staff and residents from the spread of COVID-19:

a. established adequate storage and disinfection practices for eye protection.

b. Face shields and goggles are now stored in Staff specific containers to be disinfected at the beginning and end of shift to prevent contamination.

c. Daily and spontaneous walk throughs are completed by department heads to monitor and verify appropriate eye and mouth protection is not only worn, but worn correctly over the nose and with eyes covered at all times.

2. The system will be corrected so this violation will not happen again by providing Staff with training and education on the following:

a. Infection control practices related to proper practices for use, cleaning and storage of eye and mouth protection that should be in place to protect against the spread of infection, including COVID-19.

b. Staff will be provided documented training on infection control and standard precautions, including when to don aprons when moving from providing Residents with personal care to preparing and serving food as universal workers.

System wise, Staff will be trained on infection control and standard precautions during orientation. Infection control will also be reviewed as part of annual inservice training on an ongoing basis. Competencies will be assessed during orientation and periodically there after. A focused review of infection control protocol will be part of each staff meeting.

3. This area will be evaluated during the orientation period, and with monthly staff meetings.

4. The Administrator or designee and licensed community nurse will be responsible to ensure the corrections are completed/monitored.

Based on observation, interview and record review, 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:

On 8/16/21, the main kitchen was observed to need cleaning or repair in the following areas:

* The front surfaces of drawers and cupboards were sticky to the touch;

* There were spills, splatters, debris, and crumbs in drawers and cupboards;

* The interior of the cupboards, drawers, and edges of counters were not a cleanable surface;

* The door of the microwave was cracked on the bottom edge;

* There was debris on the floor of the dry storage closet; and

* The garbage can placed next to the food prep counter was uncovered.  

The areas needing cleaning and repair were reviewed with Staff 1 (Administrator in training). She acknowledged the findings.

C240 SS=F OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1. Immediate actions taken to correct the rule violation include completing a deep clean and repair of the following in the main kitchen: The front surfaces of drawers and cupboards have been cleaned, the spills, splatters, debris, and crumbs in drawers and cupboards have been cleaned and removed, the interior of the cupboards, drawers, and edges of counters have either been painted or repaired to enusre a cleanable surface, a new microwave has been ordered, the floor of the dry storage closet has been cleaned and is free of debris, a new garbage can with a cover has been ordered to place next to the food prep counter.

2. The system will be corrected so this violation will not happen again by implementing and verifying an ongoing cleaning schedule is in use. Check lists that include all areas requiring frequent cleaning will be reviewed and updated to reflect daily, weekly and monthly cleaning and sanitizing. All staff who assist in this area will be provided training on updated cleaning and sanitizing requirements and schedules.

3. The cleaning schedule check lists will be reviewed daily, then weekly to identify any challenges or concerns/need for follow up, and completion of duties.

4.The Administrator or designee will be responsible to ensure the corrections are completed/monitored.  

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements and were updated with changes for 2 of 2 sampled residents (#s 2 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility on 7/28/21. The following required elements were not addressed in the initial evaluation:

* List of medications and PRN use;

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

* Vital signs if indicated by diagnoses, health problems, or medications

* Presence of depression, thought disorders or behavioral or mood problems;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

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

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

* Complex medication regimen;

* History of dehydration;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Drug use; and

* Environmental factors that impact the resident's behavior, including noise, lighting, room temperature.

Resident 2's evaluation identified him/her to need stand by assistance with ambulation. Interviews with staff revealed Resident 2 required two staff for all transfers. There was no update to the evaluation to reflect the change in ADL assistance.

2. Resident 3 was admitted to the facility in 7/29/21. The following required elements were not included on the move in evaluation form:

* List of medications and PRN use;

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

* Vital signs if indicated by diagnoses, health problems, or medications

* Presence of depression, thought disorders or behavioral or mood problems;

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

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

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

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

* Complex medication regimen;

* History of weight changes or dehydration;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Alcohol or drug use; and

* Environmental factors that impact the resident's behavior, including noise, lighting, room temperature.

Resident 3 was identified to have eloped from the facility on three occasions between 7/29/21 and 8/9/2021. The evaluation was not updated to reflect the elopement risk and history.

The need to ensure the initial move-in evaluation contained all required elements and was updated with changes in the first 30 days was discussed with Staff 1 (Administrator in training) and Staff 2 (RN). They acknowledged the findings.

C 252 SS=E OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation

1. Immediate actions taken to correct the rule violation include updating Resident #2's evaluation to include the following information: List of medications and PRN use, Visits to health practitioner(s), ER, hospital or Nursing Facilities in the past year, Vital signs if indicated by diagnoses, health problems, or medications, Presence of depression, thought disorders or behavioral or mood problems,  Personality, including how the person copes with change or challenging situations, Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort, List of treatments: type, frequency and level of assistance needed, Indicators of nursing needs including potential for delegated nursing tasks, Complex medication regimen, History of dehydration, Elopement risk or history, Smoking, ability to smoke safely, Drug use and Environmental factors that impact the resident's behavior, including noise, lighting, room temperature.

Also updated the evaluation with information regarding need for 2 person assistance required for all transfers.

Resident 3's evaluation has been updated to reflect the following elements that were found to be lacking in the movi in evaluation: List of medications and PRN use,  Visits to health practitioner(s), ER, hospital or Nursing Facilities in the past year, Vital signs if indicated by diagnoses, health problems, or medications, Presence of depression, thought disorders or behavioral or mood problems, Personality, including how the person copes with change or challenging situations, Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort, List of treatments: type, frequency and level of assistance needed, Indicators of nursing needs including potential for delegated nursing tasks,  Complex medication regimen, History of weight changes or dehydration, Elopement risk or history,  Smoking, ability to smoke safely, Alcohol or drug use, and environmental factors that impact the resident's behavior, including noise, lighting, room temperature. Resident 3's evaluation was also updated to reflect history of 3 recent elopements from the community.

*Health Service director has created an initial evaluation that includes all required components per OAR's, and distributed it to all sales and marketing staff. This paper document will be used as a guide for the administrator or designee to create move in evaluation until ALIS (the communities current EMAR system) can be updated to include all required components.

2. The system will be corrected so this violation will not happen again by ensuring that ALIS (EMAR and Eval/SP system) is reflective of all required pre move in components per OAR's. Until EMAR can be updated to collect the required information, all resident evaluations will be reviewed to ensure the required components are reflective of the Residents needs and preferences.  

3. This area will need to be evaluated upon admission of new resident, within 30 days of admission, quarterly and / or with a significant change of condition.

4. The Administrator or designee will be responsible to ensure the system has been corrected/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, and were updated with changes within the first 30 days, for 3 of 3 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 9/2008 with diagnoses including a traumatic brain injury.

Resident 1's bed was observed with an alternating pressure air mattress in place. The air mattress was not turned on.

Resident 1 was observed to ambulate independently with a steady gait and to stand from seated positions independently.

Resident 1's service plan did not provide direction for the use of the alternating pressure air mattress.

Resident 1's service plan was not reflective of transfer or ambulation status.

2. Resident 2 was admitted to the facility on 7/28/21 with diagnoses including dementia.

Resident 2 was observed to use a wheelchair for mobility.

In interviews with staff, Resident 2 was identified to require two staff for all transfers, had fallen several times since moving in and used a bed alarm to reduce falls.

Resident 2's service plan lacked clear direction to staff for the use of the bed alarm.

Resident 2's service plan was not reflective of ADL assistance needed.

Resident 2's service plan had not been updated with changes, including the need for two staff for transfers, falls and the use of a bed alarm.

3. Resident 3 was admitted to the facility on 7/29/21 with diagnoses including dementia.

There was no service plan in place for Resident 3.

The need for service plans to be developed prior to move in, updated with changes, reflect resident care needs, and provide clear direction regarding the delivery of services, was discussed with Staff 1 (Administrator in training) and Staff 2 (RN). They  acknowledged the findings.

C 260 SS=E OAR 411-054-0036 (1-4) Service Plan: General

Immediate actions taken to correct the rule violation for each Resident includes updating Residents #2 & #3 (Resident #1 has moved out of the community) with information related to Residents' needs, and provide clear direction regarding the delivery of services.   Resident #2's Service Plan (SP) has been reviewed and updated to reflect current need for ADL assistance, including Resident specific approaches related to dementia. Added Resident's need for 2 person assist for all transfers. History of falls and current fall reduction measures in place have also been added to the SP to include the use of a bed alarm, and clear directions for staff use.

Resident #3 has been evaluated, and a SP has been developed to reflect this resident's current care needs, and provides clear direction regarding the delivery of services, needs and preferences.

2. The system will be corrected so this violation does not happen again by ensuring that all service plans are created to reflect the Residents current status prior to move in, within 30 days, every 90 days thereafter or with any significant change of condition per Oregon Administrative Rules.

10 of 10 Resident service plans will be audited to ensure the who, what, when, how and why instructions for each area of need identified via the evaluation has clear direction for staff on personalized delivery of services.

All updates or changes to the service plan will be added to a "SPA" (service plan addendum) for staff review and should be initialled and dated. All updates to the service plan are placed in the 24 hr book for review until issue resolves or SPA will be filed in service plan binder if change is permanent.

3. Service plans will be audited on a minimum of quarterly basis during the regularly scheduled quarterly service plan process, or with a signifcant change of condition. Interim changes to service plans will be reviewed every business day to ensure accuracy and appropriatenss, allowing for changes to be made as needed.

4. The Administrator and/or designee and Licensed Nurse will be responsible to ensure the system has been completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated to staff, and the conditions were monitored, for 3 of 3 sampled residents (#s 1, 2 and 3) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 9/2019 with diagnoses including a traumatic brain injury.

* Staff reported Resident 1 had been having loose stools. Facility Observation records indicated Resident 1 was seen by the physician on 6/21/21 for "episodes of loose stools."

* Staff reported Resident 1 had been exhibiting behaviors and the physician had recently adjusted his/her medication. Resident 1 had a new physician's order for Valproic Acid 250 mg twice daily to address the behaviors.

There was no evaluation of the changes, documented monitoring at least weekly, or resident specific directions to staff for the changes in condition.

2. Resident 2 was admitted to the facility on 7/28/21 with diagnoses including dementia.

Staff reported Resident 2 had fallen from bed several times, had loose stools, and refused hygiene assistance including showers, since moving into the facility.

There was no evaluation of the changes or incidents, documented monitoring at least weekly, or resident specific directions and interventions communicated to staff for the changes in condition.

3. Resident 3 was admitted to the facility on 7/29/21 with diagnoses including cognitive impairment.

Staff reported Resident 3 had eloped from the facility on three occasions. With each elopement, the resident was observed to leave or identified to be gone immediately. Staff were able re-direct the resident back to the facility.

During the survey, Resident 3 was not observed to attempt to leave the building. The codes for the keypads at the front door and back gate had been changed.

There was no evaluation of the incidents, documented monitoring at least weekly, or resident specific directions and interventions communicated to staff for the elopements.  

The need to ensure changes of condition had documentation to reflect evaluation, monitoring to resolution at least weekly, and provided clear resident specific directions to staff, was discussed with Staff 1 (Administrator in training) and Staff 2 (RN). The staff acknowledged the findings.

C 270 SS=E OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. Immediate actions taken to correct the rule violations include updating Resident #2 and #3's record with the information identified during the survey process. (Resident #1 has moved out of the community).

Resident #2 has been evaluated for multiple falls, loose stools, refusals of hygiene assistance including showers. Resident specific directions and interventions related to these changes of condition have been  communicated to staff via SPA.

Resident #3 has been evaluated for cognitive impairment, elopement risk and recent history of 3 elopements, and current effective interventions in place to reduce elopement risk. Resident specific directions and interventions related to these changes of condition have been communicated to Staff via a SPA, and will be added to the SP permanently at the next quarterly review if indicated.

2. A comprehensive evaluation will be completed for Residents # 2 and #3, as well as for all 10 of 10 Residents currently in the community. Any Resident found to have a change of condition such as fall, attempted or successful elopement, or medication change for example, will be placed on monitoring until their condition resolves, or a new baseline can be established. Staff will know what to monitor for based off directions/interventions located on the "SPA" related to the Residents specific change of condition.

Staff will receive in-servicing specific to monitoring for short term change of condition and signifcant change of condition, appropriate documentation related to the change, and when to notify the nurse.

The community will implement a 24 hour communication system. The "24 hour binder" will be set up to include the following:

a) Shift to Shift Communication Log

b) Alert charting log

c) Service Plan Addendum

d) Signifcant Change of Condition Log

e) Weekly Skin Monitoring Log

Staff will start Short Term Monitoring / Communication System for any resident identified to have a change of condition including but not limited to, return from hospital, signs or symptoms of urinary tract infection, new or missed medication etc..

Staff will initiate the monitoring log, including resident name, change identified, start a temporary service plan addendum, and complete proper notifications to ensure they monitor resident and identify when to report concerns to nursing or physician.

The Service Plan Addendum will have specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report, who to report to and staff signature lines to sign once they have read and understood the SPA. Staff will monitor the residents status until the resident condition resolves and they are back to their baseline.

The 24 hour book / process will be reviewed daily during stand-up/clinical meetings as a means to identify potential significant changes that need to be assessed by the Registered Nurse.

3. The system will be reviewed daily and weekly to ensure compliance is maintained.

4. The Administrator or designee and Registered Nurse will be respsonsible to ensure the corrections are completed/monitored.

Based on observation, interview, and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 2 of 2 sampled residents (#s 4 and 5) who experienced falls and short term changes of condition. This is a repeat citation. Findings include, but are not not limited to:

1. Resident 4 was admitted to the facility in March 2016 with diagnoses including traumatic brain injury and dementia.

Observations of the resident, interviews with staff, review of the resident's 11/15/21 service plan, Temporary Service Plans, Observation Notes 11/01/21 through 01/03/22, Recorded Care Reports, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution in the following areas:

* Hospitalization;

* Vaccinations; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly was discussed with Staff 3 (Assistant Administrator/Universal Worker). She acknowledged the findings.

2. Resident 5 was admitted to the facility in September 2021                                             with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 10/06/21 service plan, Temporary Service Plans, Observation Notes 11/01/21 through 01/03/22, Recorded Care Reports, and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness in the following areas:

* Falls with injury and pain;

* Skin tears and bruises to multiple body parts;

* Agitation and combative behaviors;

* Hospitalization;

* Vaccinations; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and to monitor residents per their evaluated needs was reviewed with Staff 3 (Assistant Administrator/Universal Worker). She acknowledged the findings.

C 270 OAR (1-2) Change of Condition & Monitoring

1. Resident #4 will have a comprehensive nursing assessment completed by 1/28/22, appropriate follow up will be completed related to resident signifcant changes in hospitalization, vaccinations and medication changes. RN will determine and document the resident specific action or interventions that are needed to address the resident's changes. Ongoing weekly RN monitoring will be completed until resident is at baseline or a new baseline is established

Resident #5 had a signifigant change of condition assessment on 1/11/22 for hospice admission related to agitation/combative behaviors and decline in health. Ongoing weekly RN monitoring will be completed until resident establishes a new baseline or no longer resides in community.

2. A Regional RN was hired on 1/17/22 and is currently receiving training including signifigant change of condition and monitoring. Staff will receive in-servicing specific to monitoring for short term change of condition, significant change of condition and appropriate documentation related to the change, and when to notify the nurse.

3.The system will be reviewed daily, weekly, monthly and quarterly to ensure compliance is maintained.

4.The RDO/designee and Registered Nurse will be responsible to ensure the system has been corrected and is monitored.

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

Resident 2 was admitted in 7/2018 with diagnoses which included dementia.

Resident 2 had an order for psyllium (used for constipation) 3.4 mg packet, one packet by mouth daily.

Resident 2's MARs, reviewed from 8/1/21 to 8/16/21, revealed the medication was not included on the MAR and had not been administered.   

The need to ensure orders were followed was reviewed with Staff 1 (Administrator in training) and Staff 2 (RN). They acknowledged the findings.

C 303 SS=D OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

1. Immediate action taken to correct the rule violation include a comprehensive MAR review for Resident #2 to ensure all current medication orders are being carried out as prescribed. Resident #2's physician was called and informed of the lack of implementing Psyllium 3.4mg packet daily at move in. Bowel monitoring from 8/28/21 through 9/7/21 was reviewed with provider's office. Requested clarification if physician wanted to re-start resident on psyllium daily or discontinue order. Provider is faxing an order to re-start psyllium daily. No further/new medication concerns were identified with MAR review.  

10 of 10 Resident Medication and Treatment orders will be reconcilled to ensure orders are being carried out as prescribed.  

2. The system will be corrected so this violation will not happen again by ensuring a multi check system is in place to process all new orders accurately to be carried out as prescribed. A minimum of 2 staff will review and verify any new order processed prior to filing. An audit of each resident's MAR to chart to cart should be completed as part of 90 day Physician order review process to ensure all medications are in place per provider, and identify any clarifications needed.

3. Medication reconciliations will be completed on a quarterly basis prior to sending out 90 day Physician orders for review and signature. Weekly audits will be completed to review and follow up on missing medications, omissions and PRN usage.

4. The Administrator and/or designee and Licensed nurse is responsible to ensure the system is corrected/monitored.

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

Residents 1, 2, and 3's MARs were reviewed from 8/1/21 through 8/16/21, and the following was noted:

* Resident 1's MAR lacked reasons for use for one medication.  

* Resident 2 had an order for routine psyllium (used for constipation). The medication was not included on the MAR.

* Resident 3 lacked reasons for use for all medications. Resident 3 had an order for Furosemide 20 mg tablet once daily. The MAR instructed "take one tablet (2.5 mg total) by mouth daily."

The need to ensure MARs were accurate and included required information was discussed with Staff 1 (Administrator in training) and Staff 2 (RN). They acknowledged the findings.

C 310 SS=E OAR 411-054-0055 (2) Systems: Medication Administration

1. Immediate actions taken to correct the rule violation include review of Residents #2 & #3 MAR (Resident #1 has moved out of the community) and updating to ensure MAR's are currently accurate and include reasons for use for all medications and treatments. Awaiting order for from PCP regarding Resident #1's daily bowel medication to be added correctly to the MAR. In addition, Resident #3 MAR was updated with accurate dosing for Furosemide.

2. The system will be corrected by ensuring staff are following a multi check system (at least 2 staff members) to verify and implement any new order to a Residents record correctly and timely. A comprehensive medication and treatment audit will take place for all Residents prior to sending out quartly Physician orders for review and signature to ensure the following information is in place, and MAR's remain accurate and contain all required components including:  

? Current month, day and year,

? Name of medications, reason for use, dosage, route and date and time given.

? Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).  

? Resident allergies and sensitivities, if any.

? Resident specific parameters and instructions for p.r.n. medications.

? Initials of the person administering the medication.

3. The system will be reviewed with all new resident prescribed orders and on a quarterly basis. Training will be provided for all new medication techs on who to notify when new precribed medications/treatments lack a reason for use. Additionally, a quarterly medication reconillation will be completed for each Resident to ensure ongoing accuracy of all Residents MAR/TAR, including reason for use listed for all meds and treatments.

4. The Administrator and/ or designee and Licensed Nurse will be responsible to ensure the system is corrected/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure a qualified administrator was employed to work 40 hours per week. Findings include, but are not limited to:

On 8/16/21, the surveyor entered the facility at 9:00 am. Staff 1 (Administrator in training) reported she was the new Administrator.

In an interview on 8/16/21, Staff 1 revealed she had not completed the Administrator Training Course and had not registered for the course. The training is required to qualify for the position of facility administrator.

The need to have a qualified administrator employed to work 40 hours per week was discussed with Staff 1 (Administrator in training) on 8/16/21. She  acknowledged the findings.

C 355 SS=F OAR 411-054-0065 (3-4) Administrator: Administrator Requirements

1. Immediate actions taken to correct this rule violation: Administrator in training, Amber Robinson, has been enrolled in the OHCA Administrator Training Course 10/21.

2. The system will be corrected so this violation will not happen again by the facility ensuring any new Hire to the Administrator position and/or Administrator on record is a qualified Administrator per OAR's. This requiremend includes completion of the Administrator Training Course in addition to annual CEU's required and is employed to work 40 hours per week.

3. This area needing correcting will be evaluated on a quarterly basis with Administrative self audits.

4. The Administrator and/ or designee will be responsible to ensure the system is corrected and monitored.

Based on observation and interview, it was determined the facility failed to ensure a qualified administrator was employed to work 40 hours per week. This is a repeat citation. Findings include, but are not limited to:

On 01/03/22, the surveyor entered the facility at 9:30 am. Staff 3 (Assistant Administrator/Universal Worker ) reported she was the only staff working and there was no facility Administrator.

It was determined the facility failed to ensure a qualified administrator was employed to work 40 hours a week.

C 355 OAR 411-054-0065 (3-4) Administrator: Administrator Requirements

The facility is currently recruting for a qualified candidate for the administrator position and qualified staff using talent reef and Indeed as well as searching internally with the company. Designated personal at the home office are diligently recruting.

The Regional Director is assisting with oversite until a qualified administrator is hired and staff are hired to relieve assistant administrator from universal duties.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation, pre-service dementia training, and Food Handler's certification was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 3, 4 and 5) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 8/17/21 and 8/18/21.

Staff 3 (Universal Worker), hired 3/24/21, Staff 4 (Universal Worker), hired 6/14/21, and Staff 5 (Universal Worker), hired 8/4/21, lacked documented evidence of having completed pre-service orientation, pre-service dementia training and Food Handler's certification.

The need for staff to complete all required pre-service orientation, dementia training, and Food Handler's certification before working with residents was reviewed with Staff 1 (Administrator in training) and Staff 2 (RN) on 8/18/21. They acknowledged the findings.

C 370 SS=E OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1. Immediate actions taken to correct this rule violation include ensuring that #3, 4, and 5 Staff are set up to complete pre-service orientation, pre- service dementia training, and Food Handlers certification before 9.20.21.

A comprehensive audit of training records will be conducted, and any staff missing pre-service dementia training, pre-service orientation and/or food handlers certification will complete training by 10/17/21.

2. To ensure the system is corrected, any new staff hired will be assigned required trainings in the Bridge and Oregon Care Partners online training program. Prior to scheduling any new hire to work independently to provide care to Residents, Staff must have completed all required pre-service orientation, dementia training and Food Hendlers certification.

3. Staff training records will need to be evaluated on a montly basis.

4. The Administrator and/or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 3 and 4) demonstrated satisfactory performance in all job duties, were certified in First Aid and trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 8/17/21 and 8/18/21.

1. There was no documented evidence Staff 3 (Universal Worker), hired 3/24/21, and Staff 4 (Universal Worker), hired 6/14/21, had demonstrated competency in all required areas within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

2. There was no documented evidence Staff 3 and Staff 4 had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure it was documented staff had demonstrated competence in all job duties, completed First Aid certification, and abdominal thrust training within 30 days of hire, was reviewed with Staff 1 (Administrator in training) and Staff 2 (RN). They acknowledged the findings.  

C 372 SS=E OAR 411-054-0070 (5)(8) Training within 30 days: Direct Care Staff

1. Immediate actions taken to correct the rule violations for Staff # 3 & #4 include signing both Staff up for required trainings through the Bridge, and Oregon Care Partners online training program. First aid and abdominal thrust training will be provided to these staff by 9.20.21.  Staff #3 & #4 will also complete their job specific competency with preceptor sign off prior to 9.20.21.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program. Documented evidence that all new hires have demonstrated competence in all job duties, completed first aid certification and abdominal thrust training within the first 30 days of hire will be kept onsite in each employee file.  

A comprehensive audit of all staff training records will be completed, and any staff without the required demonstrated competencies within 30 days of hire will complete required trainings prior to 10/17/21.          

Required trainings in this area include:

? Role of service plans in providing individualized care

? Providing assistance with ADL's

? Changes associated with normal aging

? Identification, documentation and reporting of changes of condition

? Conditions that require assessment, treatment and observation and reporting requirements.  

? First Aid certification and abdominal thrust training.

? Job specific competency training checklist

3. Staff training records will need to be evaluated on a monthly basis.

4. Administrator or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired caregiving staff (# 9) demonstrated satisfactory performance in all job duties, were certified in First Aid, and trained in abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Training records were reviewed on 01/04/22.

There was no documented evidence Staff 9 (Universal Worker), hired 11/05/21, had demonstrated competency in all required areas within 30 days of hire including:

* Providing assistance with ADL's;

* Identification, documentation and reporting of changes of condition; and

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

There was no documented evidence Staff 9 had completed First Aid certification, and abdominal thrust training within 30 days of hire.

The need to ensure it was documented staff had demonstrated competence in all job duties, completed First Aid certification, and abdominal thrust training within 30 days of hire, was reviewed with Staff 3 (Assistant Administrator/Universal Worker). She acknowledged the findings.  

C 372

OAR 411-054-0070 (5)- (8) Training within 30 days: Direct Care Staff

1.(a) An audit of staff trainng records will be completed and any staff without the required demonstrated competencies within 30 days of hire including; providing assistance with ADL's; identification, documentation and reporting of changes of condition; conditions that require assessment, treatment and observation and reporting will be provided the training.  

(b) An audit of staff training records will be completed and any staff without the required First Aid and Abdominal Thrust training will be provided the training.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, at time of hire, the employee will be assigned required trainings in the Bridge and Oregon Care Partners online training program.

3. Staff training records will need to be evaluated on a monthly basis.

4. Regional Director/designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months, conduct fire drill every other month, and document all required components on fire drill records. Findings include, but are not limited to:

Fire and life safety records for 1/2021 to 8/16/21 revealed:

* Fire and life safety instruction was not provided to staff on alternating months;

* Fire drill records lacked the following components:

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

- Number of occupants evacuated.

* Fire drills had been conducted 1/17/21, 3/24/21, and 5/13/21. There was no drill completed in 7/2021.  

Fire and life safety training and fire drill documentation requirements was discussed with Staff 1 (Administrator in training). She acknowledged the findings.

C 420 SS=F OAR 411-054-0090 (1)(a-d) Fire and Life Safety: Drills and Instruction

1. Immediate actions taken to correct the rule violation include the Maintenance Director and Administrator review of required components under this citation per OAR's.

Fire Drills and Fire and Life Safety Training will be completed with all current staff to ensure awareness and understanding of emergency procedures including, but not limited to evacuation routes, fire extinguisher use, locating and reading the fire panel, etc. Staff will be provided with a written fire drill protocol for reference at the next all staff meeting 9/15/21.  Fire Drills will be conducted and recorded at a minimum of every other month at different times of the day, evening and night shift beginning 9/2021.

2. The system will be corrected so this violation will not happen again by ensuring a self-audit tool will be used to track Monthly Fire Drills and Fire and Life Safety trainings. Fire and Life Safety Training will be provided on alternating months. The fire drill document will include the following components: Date and time of day, location of simulated fire origin, the 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, number of occupants evacuated.

The fire drill documents and fire and life safety instruction documents will be filed in the Fire Drill/Fire and life safety binder in order of month.

3. The system will be evaluated monthly to ensure all requirements have been met and documented.

4. The Maintenance Director and Administrator or designee will be responsible to ensure the corrections are completed and monitored.

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:

Review of Fire and life safety records for 1/2021 through 8/16/2021, and staff interviews revealed the facility lacked documented evidence of the following:

* Staff providing fire evacuation assistance to residents to a designated point of safety;

* Resident instruction on fire and life safety procedures within 24 hours of admission; and

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

The need to ensure evacuation of residents to a designated point of safety, resident fire and life safety training within 24 hours of admission, and fire safety training for all resident's annually, was discussed with Staff 1 (Administrator in training). She acknowledged the findings.

C 422 SS=F OAR 411-054-0090 (1(e-h))-(2-5) Fire and Life Safety: General

1. Immediate actions taken to correct the rule violation include a review and update of the current policy directing Resident instruction on fire and life safety procedures within 24 hours of admission, as well as a written record of fire safety training, including content of the training sessions and the resident's attendance annually.

A retraining for all employees will take place at next all Staff meeting scheduled for 9/15/21 to review the community Safety Program that includes the evacuation plan for all residents to a designated point of safety in the event of an emergency requiring evacuation.

2. General Fire and Life Safety training will be provided for all new residents within 24 hours of admission and at a minimum annually. Training to include the following: alternative exit route used during fire drills. Additionally, documentation of participation in fire drills and training to assess ongoing evacuation capabilities of both residents and staff and interventions and resolution related to resident evacuation concerns identified during fire drills.

3. This system will evaluated at a minimum of monthly to ensure all requirements have been met and documented.

4. The Maintenance Director and Administrator or designee will be responsible to ensure the corrections are completed/monitored.

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

Refer to C 270, C 355, and C 372.

C 455 OAR 411-054-0105 (2-3) Inspections and Investigation: Insp Interval

Refer C270, C355, C372

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were orderly, free of litter and refuse, and pathways were maintained in good repair. Findings include, but are not limited to:

The facility grounds were toured during the survey and the following was observed:

* A wet roll of toilet paper;

* A damaged widow screen on the ground;

* Cigarette butts littered the back courtyard and planter boxes;

* An unstable BBQ grill;

* A security camera was broken with the cover hanging down; and

* Drop-off from the sidewalk to the adjacent planting bed of approximately 4 inches.

The building exterior was toured with Staff 1 (Administrator in training) on 8/16/21  She acknowledged the findings.

C 510 SS=F OAR 411-054-0200 (3) General Building Exterior

1. Immediate actions to correct the rule violation include initiating follow up on areas of non-compliance identified during survey to ensure exterior grounds are orderly, free of litter and refuse, and pathways are maintained in good repair. The grounds have been cleared of refuse including rolls of toilet paper, damaged window screens, cigarette butts, any unusable security camera equipment, and the unstable BBQ grill. Egress from the sidewalk to the adjacent planting bed will be filled in.

2. The system will be corrected so this violation will not happen again by completing consistent environmental audits. Any concerns with exterior pathways or outside areas will be identified and followed up on timely.

3.The area needing correction will be evaluated on a monthly basis with environmental audit.

4. The Administrator or Designee and Maintenance Director will be responsible to see that the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident was clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 8/16/21, the following was observed:

* Two recliner chairs in the living room areas had worn off finishes, creating an uncleanable surface;

* Multiple dark stains on the carpet throughout the common areas;

* Floor and ceiling heating grates in common areas had accumulation of dust;

* Shower thresholds in both shower rooms damaged and unclean;

* Common shower room sinks trimmed with bare wood creating an uncleanable surface;

* Baseboard moldings by room 8 were missing an approximate 2 inch corner section; and

* Wooden dining room tables worn creating an uncleanable surface.

On 8/16-8/18/21, the need to ensure all materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator in training). She acknowledged the findings.

C 513 SS=F OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors

1. Immediate actions taken to correct the rule violation include replacement of the 2 recliner chairs in the livingroom areas that were too worn to be cleanable surfaces. Carpets will be deep cleaned before 9/20/21. Floor and ceiling heating grates in common areas have been cleaned and are free of dust.

Shower thresholds in the shower rooms have been replaced and are now clean and in good repair. The common shower room sink trim has been replaced and is in good repair.  The baseboard moldings by room 8 has been replaced and the worn, Wooden dining room tables have been replaced.  The exit door to the courtyard will have a lever type handle installed.

2. Staff will receive in-servicing on reporting damaged, or broken equipment/furnishings. All Staff have been instructed on imprtance of ensuring all materials and surfaces and all equipment necessary for the health, safety and comfort of the resident is clean and in good repair. Staff will utilize maintenance request log as a means of communication regarding repair needs that are not urgent. Maintenance Director will respond to repair needs timely.

3. Weekly and monthly via weekly review of maintenance log and follow up and monthly as part of QA process.

4. The Administrator or designee and Maintenance Director will be responsible to ensure the corrections are completed/monitored.