The findings of the change of ownership re-licensure survey, conducted 06/13/22 through 06/16/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the change of ownership survey of 06/16/22, conducted 12/20/22 through 12/21/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents in the area of fire and life safety plan and practice. The lack of an emergency plan, staffing levels on the night shift, lack of resident and staff training and lack of adequate emergency evacuation equipment placed residents at potential risk of harm. Findings include, but are not limited to:

1. During the relicensure survey, 06/13/22 through 06/15/22, the survey team identified the following:

* The facility consisted of four floors, with resident rooms located on the second, third and fourth floors. Access to resident rooms was by two main elevators. During an emergency evacuation the elevators were inoperable and access to resident rooms was by two fire evacuation stairwells on each floor.

* The facility had 36 residents included four residents who needed two-person assist with transfers or a mechanical lift, (one resident on the second floor, two residents on the third floor and one resident on the fourth floor).

* Review of the staffing plan for 06/2022 provided by the facility was identified during the night shift there was one resident care assistant and one MT that was a shared employee with the first floor MCC unit which operated under a different license. On 06/14/22, Staff 1 (ED) confirmed the staffing scheduled at night and stated 1 MT covered in both MCC unit and ALF unit.

* During an observation and interview on 06/14/22, Resident 4, who resided on the fourth floor, reported s/he was paralyzed on one side of the body due to a stroke and needed two person to assist with transfers from hospital bed to wheelchair. Resident 4 stated s/he didn't recall anyone talking to him/her about fire and life safety, and was unable to answer questions related to fire and life safety and evacuation responsibilities. Resident 4 stated, "well I can't move from this bed on my own so I guess I just wait here and hope someone will come to get me."

* Resident 2, who resided on the second floor, was observed to utilize a wheelchair independently for mobility. The resident's service plan indicated the resident required staff direction to evacuate. There was no further instructions for the level of physical assist in the event of an emergency or evacuation of the building.

* During an interview on 06/15/22, Staff 1 and Staff 13 (Maintenance Director) reported there was a bariatric mechanical lift  sling located in the central laundry room on the first floor (MCC unit) that could be used to carry Resident 4, who resided on the fourth floor, down the stairwell exits during an evacuation. Staff 1 acknowledged there was not enough staff on the night shift, and the evacuation equipment was not adequate to safely transfer Resident 4 down four flights of stairs during an evacuation.

2. During an interview on 06/15/22, Staff 1 and Staff 13 identified the following:

* The facility lacked documented evidence of an emergency evacuation plan;

* Staff lacked emergency evacuation training;

* Residents lacked training in fire and life safety upon admission;

* The facility lacked proper equipment in the evacuation stairwells to safely provide two person transfers from the second, third and fourth floors; and

* Staffing levels were not sufficient in number during the overnight shift to provide two person transfers in the event of an emergency or evacuation of the building.

The need to ensure the facility had an emergency plan, adequate staffing levels on the night shift, resident and staff training and adequate emergency evacuation equipment was discussed with Staff 1, Staff 2 (Director of Nursing Services/RN) and Staff 13. They acknowledged the findings.

The survey team requested the facility to provide short-term and long-term plan of correction which was received on 06/15/22.

1. Administrative management team  including Executive Director, department managers  and Park Avenue Life Stye Management for Clinical and Operations Directors have reviewed, revised and updated all policies and procedures and intitiated trainings for all new and existing staff. Please see each citation for more information.

2.& 3. Administrative management including community and management company leadership  (Clinical and Operations Directors).participate in weekly audit reporting with quality improvements.

4. Executive Director/Adminisrtator  

3. Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

A review of Resident 2's clinical record revealed an initial evaluation had been completed on 10/12/21. There was no 30 day update or quarterly evaluation completed as of 06/15/22.

4. Resident 4 was admitted to the facility in 10/2020 with diagnoses including hypertension and cerebral infarction.

A review of Resident 4's clinical record revealed a quarterly evaluation had been completed on 07/13/21. The next quarterly evaluation would have been due three months later, on or about 10/13/21, 01/13/22, and 04/13/22, respectively. There was no documented evidence of quarterly evaluation since 7/1/3/21.

The need to ensure quarterly evaluations were completed as required by rule was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) on 06/15/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 3) and failed to complete quarterly evaluations for 2 of 2 sampled residents (#s 2 and 4), whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022.

Resident 1's move-in evaluation failed to address the following required elements:

* Customary routines, including eating and bathing;

* Interests, hobbies, social and leisure activities;

* Spiritual, cultural preferences and traditions;

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

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

* Pain including non-pharmaceutical interventions for pain;

* Recent losses; and

* Environmental factors that impact the residents behavior.

2. Resident 3 was admitted to the facility in 05/2022.

Resident 3's move-in evaluation failed to address the following elements:

* Customary routines, including eating and bathing;

* Interests, hobbies, social and leisure activities;

* Spiritual, cultural preferences and traditions;

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

* Pain including non-pharmaceutical interventions for pain;

* Recent losses; and

* Environmental factors that impact the residents behavior.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) on 06/15/22. Staff acknowledged the findings.

1. All surveyed residents evaluations have been completed with updates and current information.  

2. A tracking document /calender has been developed for use as  tool to assist nurses and adminisrator to complete evauations for each recurring SP in advance of 90 days. Addional YARDI (electronic documentation) training has been provided for staff to complete documetnation thouroghly and on time.

3. Daily clinical stand up meetings with nurses and administrator will include review of current evaluations scheduled and completed. Initial evaluations will be completed with documentation prior to move in date for SP development and all staff to follow. New move in Evaluation and SP will be reviewd and updated with in 30 days.  The timeliness of completing all evaluations will be reviewed weekly by  the Quality Improvement Committee.

4. Administrator.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of the care needs of the resident, provided clear direction regarding the delivery of services to staff, or were updated quarterly for 3 of 4 sampled residents (#s 1, 2 and 4), whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia.

Resident 1 was observed to a wear splint on the left hand. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 06/13/22 thru 06/15/22, revealed Resident 1's service plan was not reflective of the resident's status and did not provide specific directions to staff in the following areas:

* Use of splint on hand;

* Skin status on both hands;

* Use of arm sling; and

* Emergency evacuation ability.

On 06/15/22, the service plan was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.

2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

Resident 2 was observed to utilize a wheel-chair independently for mobility.

a. Observations of the resident, interviews with staff, review of the current service plan and Temporary Service plan during the survey, from 06/13/22 thru 06/15/22, revealed Resident 2's service plan was not reflective of the resident's status and did not provide instruction to staff in the following areas:

* Fall risk and interventions;

* Use of overhead trapeze;

* Use of transfer pole, next to bed; and

* Emergency evacuation ability.

b. Resident 2's service plan was last updated on 10/12/21, therefore not updated quarterly.

On 06/15/22,  the service plan was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including hypertension and cerebral infarction.

Observations of the resident, interviews with staff, review of the current service plan dated 07/13/21 and clinical records were reviewed during the survey.

a. Resident 4's service plan was not reflective of the resident's status and did not provide clear directions to staff in the following areas:

* Psychosocial: anxiety including medications and interventions;

* Evacuation ability, status and assistance;

* Condom catheter (no longer used);

* Use of a urinal and frequency for staff assistance;

* Resident meal time preferences;

* Daily routine including sleep preferences;

* Fall history and current fall interventions;

* Ambulation ability (use of a manual wheelchair and a power wheelchair);

* Two person transfers; and

* Skin issues (blisters on feet, history of pressure ulcers).

b. Resident 4's service plan was last updated on 07/13/21, therefore not updated quarterly.

On 06/15/22, the service plan was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the findings.

1. All residents SP in survey have been reviewed and updated.  

2. The tracking doucment tool will be utilized as describe in  POC for C252 to assist nurses and administrtors to track due dates and time lines for all residents' SP

3. Daily clinical stand up will include list of SP coming due and the schedule for completing similar to C252 POC. Audits will be completed twice a month to determine.

4. Nurses.

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 3 of 4 sampled residents (#s 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents' 2, 3 and 4 were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 06/15/22 and 06/16/22, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the findings.

1.Contacting designated family members along with residents to invite and attend scheduled Service Plan meetings. Service Planning Teams consist or Administrator, Nurse and one other staff member (either Med Tech or caregiver familiar with  the resident service needs) will particiapte in each SP. Service Plan meetings and teams will be scheduled for two different days each week.

2. By setting up  two reoccuring weekly meeting with advance notice to all participants will help to ensure team attendance and timley completion of SP.

3. Weekly as stated in 2 above.

4. Administrator.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs, service planned interventions and document weekly progress until the condition resolved  for 3 of 4 sampled residents (#s 1, 2 and 4) reviewed for change of conditions. Findings include but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia.

Resident 1 was observed during the survey to wear splint on the left hand.

Resident 1's clinical records were reviewed during the survey and revealed the following:

* 04/19/22 - Fall with emergency room visit and received a diagnosis of left wrist fracture; and

* 05/03/22 - Cast in place on left wrist.

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

On 06/15/22, the above information was shared with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

Resident 2 was observed during the survey to use a wheelchair independently for mobility.

a. Resident 2's current service plan indicated the resident was "a high fall risk" and provided interventions to reduce falls.

Resident 2's clinical record revealed the resident was noted to have fallen seven times between 12/08/21 and 06/13/22.

There was no documented evidence Resident 2's fall interventions were evaluated with each instance and monitored for effectiveness.

The need to monitor interventions related to the ongoing falls experienced by Resident 2 was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN) on 06/15/22. They acknowledged the findings.

b. Resident 2's clinical records revealed s/he had the following short-term change of conditions that were not monitored with weekly progress notes until resolution:

* 03/01/22  - Skin issue on groin area;

* 03/01/22  - Increase in confusion/disorientation at times, hallucination have become more bothersome; and

* 03/17/22 - Decreased dose of Meloxicam [a medication to treat osteoarthritis].

The need to monitor changes of condition was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN) on 06/15/22. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including hypertension and cerebral infarction.

Interviews with staff, review of the current service plan dated 07/13/21, Temporary Service Plans (TSP's) and progress notes dated 03/11/22 through 06/12/22 were reviewed during the survey.

a. Resident 4 had the following short-term changes of condition that lacked documented monitoring through resolution:

* 03/25/22- Discontinued Clobetosol ointment;

* 03/29/22- Discontinued Clotrimazole cream and Triamcinolone ointment;

* 03/29/22- New medication Nystatin topical powder;

* 03/29/22 -New medication Amlodipine 5 mg;

* 04/06/22- Medication change - Olanzapaine increase to BID;

* 04/14/22- New medication Hydrochlorothiazide 25 mg daily;

* 04/19/22- Discontinue Lidocaine patch and increase Tylenol;

* 04/22/22- New medication Nacinamide 500 mg twice daily; and

* 06/13/22- Increase Amlodipine to 10 mg.

b. Resident 4 had the following falls that lacked monitoring of the fall interventions for effectiveness:

* 04/26/22- Unwitnessed fall at 6:30 pm in resident unit. The documented intervention directed staff to avoid the use of an incontinent pad when the resident was in the wheelchair.

* 04/26/22- Unwitnessed fall at 7:30 pm fall in resident unit. There was no documented evidence an investigation of the fall was completed and there was no documented evidence the service planned  fall intervention was monitored for effectiveness; and

* 06/12/22- Unwitnessed fall from bed which resulted in a skin tear to the right elbow and some pre-existing blisters on the residents feet were opened. There was no documented monitoring of the service planned interventions to ensure the intervention was being followed or was effective to prevent future falls.

The need to monitor changes of condition until resolution and to ensure fall interventions were reviewed for effectiveness was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN) on 06/15/22. They acknowledged the findings.

1. Resident 1, 2, 4 have had updated evaluations and Service Plans.

2. A change of conditon system now includes training all staff on  regulations for observing, reporting, monitoring and documenting any noticiable changes in a residents routine or overall conditon. Training on the mandatory use of tools is in process and inlcudes:  STOP AND WATCH  for cargivers and SBAR for Med Techs and Nurses. Alert charting and Temporary or other changes on the SP will be directed by nurses and communicated to health services staff. Nurse is on call for any questions or concerns regarding a resident potential change of condition. Documentation will follow in the progress notes inlcuidng reviewing effectviness of  interventons  and  when a short term condtion has been resolved and wll be taken off ALERT.  An ALERT White Board will be located in MEDROOMS with HIPPA protections for daily tracking at a glance and shift change reporting.

3. Nurses will follow up daily on STOP & Watch and review the ALERT Charting daily. Weekly clincal standup meetings will include  review of all residents

CoC on ALERT.  

4. Nurses and Administrator.

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

Resident 1 was admitted to the facility in 03/2022 with diagnoses including dementia.

During the acuity interview on 06/13/22, the resident was identified to experience an injury to the left wrist.

Resident 1 was observed during the survey to wear a splint on the left hand.

The clinical record, including the current service plan dated 03/22/22, progress notes dated 03/29/22 through 06/13/22, and Temporary Service Plans (TSPs), were reviewed during the survey and revealed the following:

* 04/19/22 - Alert charting for an injury fall. Resident reported pain, swelling and decrease of range of motion on left wrist;

* 04/19/22 - Resident was sent out to emergency department. The discharge visit notes indicated the resident had a left wrist fracture. The discharge instructions indicated to wear a brace for the next two weeks and no heavy lifting, pushing or pulling greater than three to five pounds; and

* 05/03/22 - Cast was in place on left wrist.

Resident 1 experienced a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's condition which included findings, a description of the resident status and interventions made as a result of the assessment.

On 06/15/22, the failure to conduct an RN assessment following a significant change in condition was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the findings.

1. See POC for C 270. Nurses will follow up with in 24 hours of any potential change of condition with a nursing assessment and documentation in progress notes; either a temporary SP or change to SP depending on resident's condition. All accidents, injuries, emergency room encounters will be called to the nurse on call if nurse is not on duty at the time of the incident.

2.  See POC  C 270 for observing and reporting.

3. Daily stand up meetings will include any accidents injuries and emergency room visits.

4. Nurses and Adiminstrator

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 1 of 2 sampled residents (# 2) who was receiving services from  outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2021 with diagnoses including  Parkinson's disease and was receiving outside nursing care for his/her foot.

A review of the resident's clinical record identified the following the recommendation was not implemented:

* 05/04/22 -  Place "lotion daily to lower calves and feet" and "elevate feet when possible".

There was no documented evidence the recommendation was communicated to staff, made part of the resident's service plan, or implemented.

On 06/15/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 3 (Director of Nursing Service/RN). They acknowledged the findings.

1. Resident #2 service plan and MARs have been updated.

2.Nurses will review all care povider notes weekly to ensure incusion of any new instructions for caregivers or MedTechs on the MAR and SPs as indicated. Nurses will also document a progress note regarding the care note and label the note: Coordination of Care.

3. Weekly

4.Nurses  

Based on interview and record review, it was determined the facility failed to ensure adequate professional oversight for a safe medication system for 1 of 2 sampled resident (# 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

During an interview on 06/14/22 at 10:00 am, Resident 2 stated his/her Parkinson's medication was not administered as scheduled.

Resident 2's 10/15/21 physician orders indicated to administer Pramipexole 0.75 mg (a medication to treat Parkinson's disease) five times a day. That medication is a time sensitive medication and in order to achieve therapeutic level, required specific administration time frames between doses.

The Resident 2's 06/01/21 through 06/13/22 MAR noted Pramipexole 0.75 mg was scheduled to administer at 5:30 am, 9:00 am, 12:00 pm, 3:00 pm and 6:00 pm.

Resident 2's medication administration time logs for the Pramipexole 0.75 mg from 06/01/22 through 06/15/22 was reviewed and revealed the following:

* Staff documented, six occasions, Pramipexole 0.75 mg was administered to the resident more than one hour later than as scheduled, including 2 hours and 18 minutes late on 06/09/22.

*  Staff documented, four occasions, Pramipexole 0.75 mg was administered to the resident too closed together between doses, including in 57 minutes between doses on 06/08/22.

* Staff documented, two occasions, Pramipexole 0.75 mg was administered to the resident too widespread between doses, including four hours and 21 minutes between doses on 06/05/22.

2. During the survey administrative oversight of the medication and treatment administration system was found to be ineffective based on deficiencies in the following areas:

* C 302: Tracking Control Substances;

* C 303: Medication and Treatment Orders; and

* C 305: Resident Right to Refuse.

The need to ensure the facility had a safe medication administration system and the overall medication and treatment administration system were reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) during the survey. They acknowledged the findings.

1.All residents cited on survey have been reviewed and addressed by nurses with specific written and verbal instructions  with Med Techs. YARDI system has been updated to flag medical orders for time sensitve administration and other tasks related to accurate administrations such as Blood pressures, physical postioning, empty stomach or with food are incuded in the MAR.  Policies and procedures have been reviewed and updated to include time frame for other medicaitons without time sensitivity that include time frames for Breakfast, Lunch, Dinner and Bedtime administration. If medical orders do not prohibit resident preferences , these will be included on the SP along with time sensitive meds. All resident refusal have been faxed to prescribers.Oregon Care Partners traing on Role of the Med Tech and Safe Mediction Use for Older Adults  has been scheduled for Med Techs and Administrator.

2 & 3. Nurses will review all medical orders and ensure accuracy for time sensitive medicaions administered on time along with MT following the complete medical order and notification to prescriber for all refusals with reason why resident is refusing if known. Nurses will complete audits 2 times weekly for orders and administration accuarcy and follow up. Nurses will , track and report medication errors; and direct staff in the overall safety and well being of the resident in each occurance.

4. Nurses will track and report to Quality Improvement Committee weekly which inlcudes the Administrtor.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility, for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Drug Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2021.

Resident 2 had signed physician orders for Hydrocodone/Acetaminophen 5-325mg every 6 hours as needed for pain.

Resident 2's 05/01/22 through 06/13/22 MAR and the Controlled Substance Disposition Log were reviewed and revealed the following:

* Staff documented the Hydrocodone/Acetaminophen 5-325mg was dispensed on the Controlled Substance Disposition log on multiple occasions between 05/01/22 and 06/13/22.

* There was no documented evidence on the MAR the dispensed medication was administered to Resident 2.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed on 06/15/22 with Staff 1 (ED) and Staff 2 (Director of Nursing/RN). They reviewed the documentation and acknowledged the discrepancies.

1. YARDI system has been updated for recording time of administration. Medication record has been reconciled for Res #2 medication administration.

2.Med Tech retraining and review of P&P to sign medicaiton out of Control Book at the same time MAR is recorded as administered to avoid time discrepencies.

3. Audtis 2 times weekly

4. Nurses.R

2. Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

Resident 2's physician orders, dated 10/15/21 and 06/01/22 through 06/13/22 MAR was reviewed during the survey.

The following prescribed medications were not administered as prescribed on 06/07/22:

* Donepezil 10 mg daily to treat Alzheimer's disease; and

* Ramelteon 8 mg daily at bedtime to treat trouble in sleeping.

The facility's failure to follow physician orders as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) on 06/15/22. They acknowledged the findings.

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

1. Resident 4's physician orders, dated 04/19/22, and 06/01/22 through 06/13/22 MAR was reviewed during the survey.

The following prescribed medications and treatments were not administered as prescribed:

* Esomeprazole DR 20 mg, give daily 30 minutes before breakfast;

* Niacinamide 500 mg, give twice daily with dinner; and

* Three incidents when daily blood pressure wasn't taken.

During an interview on 06/14/22 at 8:35 am, Staff 4 (MT) reported Resident 4 was consistent with meals and always had a large breakfast between 8:00 am and 8:30 am and Esomeprazole was given at 8:00 am and Resident 4 ate dinner at 4:30 pm. Staff 4 confirmed Niacinamide was administered at 8:00 pm and was not given with food.

The need to ensure physician orders were administered as prescribed was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) on 06/15/22. They acknowledged the findings.

1. Resident # 2 and 4 MAR and SP have been updated with medical orders. Medication error reports have been completed.

2. Review P&P with MedTechs for following medical orders including how and when to administrer medicaitons.

3. Nurses wil conduct audits twice weekly.

4.Nurses  

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

Resident 2 was admitted to the facility in 09/2021 with diagnoses including Parkinson's disease.

Resident 2's 06/01/22 through 06/13/22 MARs were reviewed during the survey. Staff documented the resident refused physician-ordered, Optive Sens eye drops, Polyethylene Glycol for bowl movement and Refresh eye drops on multiple occasions.

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

On 06/15/22, the refusals were reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing Service/RN). They acknowledged the findings.

See POC C 300

Residents PCP has been notified of refusals. Policies and Procedures have been updated to include reporting every time a resident refuses. Med Techs have been instructed on P&P and will document on the electroinc MAR along with faxing the PCP.

2. Nurses will audit documenation of refusals weekly. Med Tech will include refusals and notficaitons in shift to shift reports.

3. Nurses will audit and report 2 times weekly.

4. Nurses.  

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident during the night shift. Findings include, but are not limited to:

1. During the entrance conference and acuity interview on 06/13/22 the following was identified:

* The facility consisted of four floor with resident rooms located on the second, third and fourth floor;

* The facility had 36 residents;

* Four residents needed two-person assist with transfers or a mechanical lift (one resident on the second floor, two residents on the third floor and one resident on the fourth floor); and

* Six residents needed full assistance in ADLs.

The facilities staffing plan for 06/2022 was as follows:

* During the night shift, there was one caregiving staff in assisted living and one MT that was a shared employee between the first floor MCC and assisted living which operated under a different license. On 06/14/22, Staff 1 (ED) confirmed the night shift staffing plan.

2 a. 06/15/22 at 8:58 am, Staff 16 (RCC) reported there were three residents in rooms 221, 401 and 419, who required scheduled and unscheduled medication administration during the night shift. She further stated there were a few residents in rooms 221, 300 and 301 who required two person assist with transfer and room 401 required incontinent care during the night.

b. During an observation and interview with Resident 4 on 06/14/22, who resided on the fourth floor,  s/he was observed to be paralyzed on one side of the body due to a stroke, and required two people to assist him/her with transfers from hospital bed to wheelchair.

c. Resident 2, who resided on the second floor, was observed to utilized a wheel-chair independently for mobility. The resident's service plan indicated the resident required staff direction to evacuate. There was no further instruction for the level of physical assist in the event of an emergency or evacuation of the building.

3. On 06/13/22 at 4:45 pm, the surveyor requested a facility staffing policy or a tool to determine number of caregiving staff needed to provide scheduled and unscheduled residents' care needs. The requested staffing policy was not provided during the survey.

During an interview on 06/15/22, Staff 1 and Staff 2 (Director of Nursing Services/RN) acknowledged there was not enough staff on the night shift to meet the scheduled and unscheduled needs of the resident.

1. Staffing with full time employees inlcudes the following: Day shift= 1 Med Tech + 3 caregivers.Swing  shift= 1 Med Tech+3 cargvers Night Shift= 1 Med Tech + 2 caregivers. This represents dedicated staff in MC.

2. Acuity Based Staffing Tool used and updated monthly as needed to track resident care for scheduled and unscheduled needs and staffing will be adjusted as required.

3. Monthly or as needed as residents' condition change and or new residents move in.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure documentation that 3 of 3 sampled newly-hired employees (#s 7, 9 and 10) completed pre-service orientation and pre-service dementia care training prior to assuming their job duties. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED), Staff 2 (Director of Nursing/RN) and Staff 14 (Sales Director) on 06/15/22. The following deficiencies were identified:

Staff 7, 9 and 10 (Resident Care Assistants) were hired on 02/02/22, 04/05/22 and 12/21/21, respectively.

1. There was no documented evidence Staff 9 (Resident Care Assistant) completed pre-service orientation.

2. Staff 7, 9 and 10 who provided direct care to residents, lacked documented evidence they completed approved pre-service dementia training prior to providing care to residents.

The need to ensure documentation of completed pre-service orientation and pre-service dementia training prior to beginning job duties was reviewed with Staff 1, Staff 2 and Staff 14 on 06/15/22. They acknowledged the lack of training documentation.

1. Staff 7,9,10 employment training records reviewed. Trainng deficiencies identified and completed, including Pre-Service Dementia .

2. Review of all employee files for completed trainings has been completed with deficiencies noted. Each employee will complete all required trainings with out delay. A tracking document has been created for each employee file with all training topics identified and listed by required completion dates including DOH; with in 30 days and annually. A copy of training requirments and due dates provided to all employees ( and new employees on DOH).

3. Review new employee training records before scheduled work begins and again with in 2 weeks from DOH.  Post annual training dates with topics for all staff. Issue each emplolyee a self tracking document for each required training and due dates

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired direct care staff (# 9) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 1 (ED), Staff 2 (Director of Nursing/RN) and Staff 14 (Sales Director) on 06/15/22 identified Staff 9 (Resident Care Assistant) lacked documented evidence competency was demonstrated in the following required areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1, Staff 2 and Staff 14 on 06/15/22. They acknowledged the findings.

1. Staff #9 training has been completed.

2.All caregivers and MedTechs will demonstrate competency with in 30 days of hire including but not limeted to the following: The role of SP in providing care; Providing assistance with ADLs; changes associated with normal aging and identifiication, documentation and reporting change of condition, including any that require assessment, treatment, observatiion and reporting; general food safety, serving and sanitation.Along with each department manager tracking, each employee will self track required training topics, deadlines and dates of completion.Certificates of completion will be copied into employee training file. Annual training topics schedule will be posted for all staff . Each topic will list what type of competency is needed: Certificate of knowldege and or Return Demonstration. List of employees and training competencies will be distributed to all employees and mangers.  Employees scheduled to work shifts in MC will have additional training topics listed for competency demo for total of 12 hours including Dementia Care . All staff will complete 2 hours of Infection Control via Oregon Care Partners.

3. Weekly reports in standup and monthly to Quality Improvement Committee

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled direct care staff (#s 4, 6 and 8) completed a total of 12 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN) and Staff 14 (Sales Director) on 06/15/22. The following deficiencies were identified:

Staff 4 (MT), Staff 6 (MT) and Staff 8 (Resident Care Assistant), hired 01/06/20, 04/24/21 and 05/07/21, respectively, lacked documentation of annual in-service training including six hours of annual dementia care training.

The need to ensure long term direct care staff completed 12 hours of in-service training annually was reviewed with Staff 1, Staff 2, and Staff 14 on 06/15/22. They acknowledged the findings.

1. Staff # 4, 6, 8. training deficiencies have been identified and completed and are up to date for Pre Service Dementia and annual training for the current year accoridng to their due dates ( DOH).

2. Nurses (supervisors) conduct assessments of each direct care employee competency and complete training records for dates of completion with both signatures.

3. Tracking documents with list of each required training and competency distributed to nurses and each direct care staff to record and complete. Completed record placed in employee training file with tracking documents completed.

4. Administrator

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and failed to provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:

Fire drill records from 11/2021 through 06/2022 were reviewed on 06/13/22. The facility lacked documented evidence fire drills were conducted every other month and included the following required components:

* The escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills, and Facility staff lacked training on the designated points of safety.

On 06/13/22, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (ED) and Staff 13 (Maintenance Director). They acknowledged the findings.

1. Fired drill training records updated to include all required compentents including: Fire drills conducted every other month; escape route used; problems encountered and residents' resistence or failed to participate in drills; evacuation Evacuation time period needed and # of occupants evacuated. A fire and life safety instrucion in-service for all staff is scheduled for completion on alternate months.

2.Monthly audits of all required documenation for fire and life safety trainings will be conducted and reported to Quality Assurance Committee.

3.Monthly

4. Maintenance Director

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and annually. Findings include, but are not limited to:

Fire and life safety records reviewed on 06/13/22 lacked documented evidence the following required elements were completed:

* Instruction to residents on fire and life safety procedures within 24 hours of admission.

* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (ED) and Staff 13 (Maintenance Director) on 06/13/22. They acknowledged the findings.

1. All new residents are provided written instructions on fire drills and life safety procedures with in 24 hours of move-in.

2. Resident signatures are obtained verifying receipt of information. An addendum has been added to all new move in paperwork to include review of specific instructions regarding evaucation methods, responsibilities during drills and meeting places outside of the buidling.

The move in list of items is updated to include requirements for all new residents.

3. Every new move-in.

4. Maintenance Director.