The findings of the re-licensure survey, conducted 05/30/23 through 06/01/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 06/01/23, conducted 08/16/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Resident 4 moved into the facility in 05/2014 with diagnoses including hypothyroidism.

The resident's MAR dated 05/01/23 through 05/29/23, corresponding progress notes, and physician orders were reviewed.

Resident 4 had an order for levothyroxine 50 mcg to be given by mouth every morning related to hypothyroidism.

The MAR was blank for levothyroxine on the following dates:

* 05/05/23;

* 05/09/23;

* 05/11/23;

* 05/15/23;

* 05/17/23; and

* 05/25/24.

On 05/30/23 at 2:19 pm, the surveyor and Staff 13 (MT) observed/checked the MAR and medication supply. Staff 13 was unable to verify if the above orders had been followed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Director of Assisted Living) on 06/01/23 at 12:14 pm. She acknowledged the findings.

1) Resident #4 corrected resident records, Physician's orders clarified, reviewed, and adjusted specifically to resident needs, resident records updated.

2)We completed a review of the Physician Orders vs. EMAR orders to verify Physician Orders are carried out as written and signed by the Health Care Provider. In-service staff on components of medication administration.

3) As orders change or new ones are implemented.

4) Director of Assisted Living, community RN, Med-Aides, Executive Director, Assistant Executive Director

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included dosage of medication, medication specific instructions, and provided clear parameters and instructions for PRN medications for 2 of 4 sampled residents (#s 1 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 05/2014 and had a history of eye infections.

The resident's MAR dated 05/01/23 through 05/29/23 was reviewed.

The following medication lacked the dosage to be administered and specific instructions to staff:

* Erythromycin 5 mg/gm - use ointment as directed in left eye every night at bedtime (for eye infection).

On 05/30/23 at 2:28 pm, Staff 13 (MT) confirmed there was no dosage or additional instructions to staff included in the electronic MAR or on the medication container.

The need to ensure medications on the MAR included the dosage and medication specific instructions was discussed with Staff 1 (Director of Assisted Living) on 06/01/23. She acknowledged the findings.

2. Resident 1 moved into the facility in 5/2023 and had a history of leg pain.

A review of the 05/09/23 through 05/30/23 MAR and current physician orders, dated 05/09/23, identified the following deficiencies:

a. The MAR lacked parameters and instruction to staff for multiple PRN medications including acetaminophen, tramadol, Voltaren gel and Salon pas patches, all prescribed for pain; and

b. The MAR lacked instructions to staff on when to administer multiple PRN medications, including Miralax and milk of magnesia, both prescribed to treat constipation.

The need to ensure resident specific parameters and instructions for PRN medications were provided for staff to follow was reviewed with Staff 1 (Director of Assisted Living) and Staff 3 (Assistant Executive Director) on 06/01/23. They acknowledged the findings.

1) Resident #4, corrected eMAR with specific dosage and additional instructions to staff. MAR reviewed and updated reflective of instructions of medications

prescribed by health provider and transcribed to MAR accurately.  Resident #1, reviewed PRN pain

medication and PRN bowel care medication and clarified with Healthcare Provider. Based on resident needs, new orders were sent, reviewed, and updated in eMAR to move pain medications from PRN to

routine. PRN medications for pain and bowel care updated with specific parameters and instructions for staff to follow.  

2) Completed an audit of the Physician Orders vs. EMAR orders to verify Physician Orders are carried out as written and signed by the Healthcare Provider.

In-service staff on components of medication administration.

3) As orders change or new ones received/implemented.

4) Director of Assisted Living, Community RN, Med-Aide, Executive Director, Assistant Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 7, and 10) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/31/23.

There was no documented evidence Staff 6 (CG), Staff 7 (CG), or Staff 10 (CG), hired 03/01/23, 04/19/23, and 12/08/22 respectively, demonstrated satisfactory performance in one of more of the following required areas:

* 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 which require assessment, treatment, observation, and reporting; and

* General food safety, serving, and sanitation.

The need for direct care staff to demonstrate satisfactory performance in assigned job duties within 30 days of hire was discussed with Staff 1 (Director of Assisted Living) and Staff 3 (Assistant Executive Director) on 05/31/23. They acknowledged the findings.

1) Staff #6, #7, and #10 have Caregiver Orientation Training Verification to demonstrate satisfactory performance in assigned job duties. Training verficiation is in process and will be completed by 7/31/2023.   

2) Assisted Living Care staff to complete and document required traninings within the first 30 days of employment. HR shall review new hire files to verify completion in required time frame.   

3) Upon hire and at 30 days post hire.

4) Director of Assisted Living, HR Coordinator, Executive Director, Assistant Executive Director.  

Based on interview and record review, it was determined the facility failed to ensure employees completed 12 hours of annual in-service training, including a minimum of six hours on dementia care, for 2 of 3 long-term staff (#s 8 and 9). Findings include, but are not limited to:

Staff training records were reviewed on 05/31/23.

1. Staff 8 (CG), hired 08/2011, failed to have documented evidence of completing 12 hours of annual in-service training including six hours of annual in-service training related to the care of the dementia resident, between 08/2021 and 08/2022.

2. Staff 9 (CG), hired 02/2009, failed to have documented evidence of completing 12 hours of annual in-service training on topics related to the provision of care in a CBC setting, between 02/2022 and 02/2023.

The need to ensure long-term staff complete the required number of annual training hours, including dementia care, was discussed with Staff 1 (Director of Assisted Living) and Staff 3 (Assistant Executive Director) on 05/31/23. They acknowledged the findings.

Staff #8 and #9 identified is needing to complete annual training. Staff #8 is scheduled to complete annual and dementia requirements by July 31, 2023. Staff #9 is scheduled to finish completing 12 hours of annual in-service by July 31, 2023.

2) Assisted Living Care staff to complete and document  required traninings. HR shall review staff files to verify annual training requirements have been met.

3) Upon hire, completion of training monthly and prior to expiration

4) Director of Assisted Living, HR Coordinator, Executive Director, Assistant Executive Director.  

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

A review of fire and life safety records provided from 11/2022 through 05/2023 identified the following deficiencies:

* Lack of documented evidence fire drills were conducted every other month. Fire drills were conducted 11/2022, 03/2023 and 04/2023.

* Fire drills conducted did not consistently document all required components including:

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

    - Evacuation time period needed;

    - Number of occupants evacuated; and

    - Evidence alternate routes were used during fire drills.

* Lack of documented evidence fire and life safety instruction was provided to staff on alternate months. One training had occurred during the six month review period.

The need to ensure fire drills were conducted and documented in accordance with Oregon Fire Code, and fire and life safety instruction was completed on alternate months was discussed with Staff 1 (Director of Assisted Living), Staff 4 (Maintenance Assistant) and Staff 12 (Maintenance Assistant) on 05/31/23. They acknowledged the findings.

1) Fire and Life Safety drills will be completed on alternate months with documentation in accordance to Oregon Fire Code and all drill components.

2) Scheduled monthly drills.

3) Director of Assisted Living, Executive Director or Assistant Exective Director to review monthly for completion.  

4) Director of Assisted Living,Executive Director, Assistant Executive Director