The findings of the re-licensure survey conducted 11/28/22 through 12/01/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

A situation was identified where there was a failure of the facility to comply with the Department's rules that was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0055(1)(a) Medication and Treatments-Medication and Treatment administration systems.

The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first revisit to the re-licensure survey of 12/01/22, conducted 08/14/23 through 08/16/23, 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 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:             three times a day

The findings of the second re-visit to the re-licensure survey of 12/01/22, conducted 11/16/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

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

During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

1.  A situation was identified which constituted an immediate plan of correction to residents' health and safety in the following area:

OAR 411-054-0055 (1)(a) Medication and Treatment Administration Systems.

The facility put an immediate plan of correction in place during the survey and the situation was abated.   

2.  Refer to deficiencies in the report.

Refer to all other citations. There is a new interim administrator that will submit documents the last week of December. Recruitment continues for a permanent administrator. A new management consulting company is in place.

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

During a tour of the environment on 11/28/22, there were no postings related to the administrator or designee in charge or the current facility staffing plan in an accessible or conspicuous location.

The findings were reviewed with Staff 1 (ED designee) on 11/29/22. He acknowledged the findings.

1. The required postings for for administrator or designee and staffing are posted.

2. Administrator or designee will do daily walkthroughs to ensure postings are current.

3. Daily for one month and then move to weekly audits, and when the ABST is updated.

4. Admnistrator and MC Program Director.

Based on interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose records were reviewed. Findings include, but are not limited to:

During the survey, resident records were reviewed and were found to be missing, inaccurate or incomplete in multiple areas, including signed physicians' orders, move in evaluation, initial service plan, service plans, evaluations, monitoring and incident investigations.  

On 12/01/22, the need to ensure facility records were accurate and complete was shared with Staff 1 (ED designee) and Staff 24 (Consultant). No additional information was provided.

Refer to C231, C252, C260, C270, C280, C290, and C303 related to resident records and documentation.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any threat to the health, safety or welfare of residents for 1 of 1 sampled resident (#3) who had a catheter. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2022 with diagnoses including depression and adult failure to thrive.

Observations were conducted during the survey to determine adherence to universal precautions for infection control.

* Multiple observations during the survey, revealed Resident 3's catheter bag and tubing was laying on the apartment floor. The resident's floor had food debris and dirty clothing near the catheter bag. Resident 3 stated s/he emptied the catheter bag when needed.

* On 11/29/22 three Resident Assistants stated they did not provide any assistance related to catheter care for the resident.

The need to ensure proper infection control protocols including keeping the catheter bag and tubing off of dirty surfaces was discussed with Staff 24 and Staff 25 (Consultants).  No additional information was provided.  

1. Resident 3 catheter bag and tubing are secured and not touching the floor. Med techs have been trained in how and why to secure the catheter bag and tubing.

2. All direct care staff will be trained by nurse consultant in how to handle and secure catheter bag and tubing for proper infection control. All direct care and med techs will be trained during orientation to perform catheter bag and tubing related competencies. Observation of proper bag and tubing placement during administrator walk throughs.

3. Daily, weekly, monthly.

4. Administrator, licensed nurse.  

Based on interview and record review, it was determined the facility failed to ensure an incident was promptly investigated to rule out abuse and neglect and failed to report to the local SPD office as required for 1 of 1 sampled resident (#4) related to a medication error that resulted in a skin injury. Findings include, but are not limited to:

Resident 4 was admitted in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

Resident 4's clinical record and charting notes dated 09/06/22 through 11/16/22 were reviewed and identified the following:

Resident 4 had a physician's order to apply a nicotine patch to the middle of his/her back area every 24 hours.

On 10/16/22 staff documented a nicotine patch dated 10/09/22 was found on the resident's skin. The patch had not been removed for five days and "due to prolonged duration of patch placement," the resident had developed a wound. There was no further information about the incident or injury.

There was no documented evidence the facility had conducted an immediate investigation of the incident to include the time, date, description of the event, response of staff at the time of the event, follow up action, or administrator review. Additionally, there was no evidence the facility had ruled out abuse and neglect.

During an interview on 11/30/22, Staff 16 (MT) verified the resident did not have any unresolved skin issues.

The need to ensure resident incidents were promptly and thoroughly investigated to rule out abuse and neglect was discussed  with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

The facility was asked to report the incident to the local SPD office and provided confirmation of the report prior to survey exiting.

1. Resident 4 skin was assessed during survey and no concerns were noted. An investigation was conducted during the survey. Med techs will be trained in application, removal, and documentation of medication patches. All staff will be trained again on abuse and neglect reporting. Management staff will be trained on investigation, reporting, and documentation. All staff training on abuse and neglect reporting and resident rights scheduled for December 29, 2022.

2. Regular med tech meetings will be scheduled for review of exceptions and variances, other med tech training topics. Incident reports will be review within 24 hours of incident occurance, investigationm started, and reporting done as required. Incidents and concerns will be reviewed in the clinical meeting.

3. Daily, weekly, and with each incident.

4. Administrator or designee, RN, operations consulting team.   

3.  Resident 3 was admitted to the facility in 09/2022 with diagnoses including depression and adult failure to thrive.

There was no documented evidence a move-in evaluation was completed before the resident moved into the facility. There was no documented evidence the required elements were reviewed nor was there evidence of an updated evaluation within the first 30 days of admission.

The lack of an initial move in evaluation with subsequent updates was discussed with Staff 24 and Staff 25 (Consultants) on 11/30/22. No additional information was provided.

4. Resident 1 was admitted to the facility in 01/2020 with diagnoses including insulin dependent diabetes.

Resident 1's clinical record contained an evaluation completed on 07/12/22. The next quarterly evaluation would have been due on 10/12/22. There was no documented evidence of any evaluation completed after 07/12/22.

The need to ensure a quarterly evaluation was completed timely was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants) on 11/30/22. They acknowledged the findings.

5.  Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

A review of Resident 4's clinical record revealed a quarterly evaluation had been completed on 02/12/22. The next quarterly evaluation would have been due three months later, on or about 05/12/22.

There was no documented evidence a recent quarterly evaluation had been completed as of 11/29/22.  

The need to ensure quarterly evaluations were completed timely was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

6.  Resident 5 was admitted on 10/02/22 with diagnoses including cerebral palsy.

The initial evaluation dated 10/02/22 failed to address the following required elements:

* Physical health status including: list of current diagnoses, list of medications and PRN use, visits to health practitioner(s), ER, hospital or NF in the past year, and vital signs if indicated by diagnosis(es), health problems or medications.

The need to ensure the initial evaluation included all of the required elements was discussed with Staff 24 and Staff 25 (Consultants) on 11/30/22. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements for 2 of 2 sampled residents (#s 3 and 5) whose move-in evaluations were reviewed, and quarterly evaluations were being completed for 4 of 4 sampled residents (#s 1, 2, 4, and 6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2's clinical record contained an evaluation completed on 03/09/22. The next quarterly evaluation would have been due on 06/09/22. There was no documented evidence of an evaluation completed after 03/09/22.

On 12/01/22, need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

2. Resident 6's clinical record contained an evaluation completed on 05/14/22. The next quarterly evaluation would have been due on 08/14/22. There was no documented evidence of any evaluation completed after 05/14/22.

On 12/01/22, the need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 1, 2, 4 and 6 evaluations will be updated. Consultant provided Resident Evaluation Checklist and paper Resident Evaluation. The ABST will be updated with evaluation and service plan updates. Staff will be trained in how to conduct an evaluation and when and what information should be collected. All resident evaluations will be reviewed and updated.

2. A new evaluation form will be implemented that includes all required elements. Once all evaluations are updated, an evalation schedule will be developed and implemented to correspond with quarterly service plan dates. A new process for move in screening and evaluation will be implemented. Consultant will provide a move in process checklist and train staff to ensure all required information is received and reviewed prior to move in.

3. Weekly, monthly.

4. Administrator, designee.

2.  Resident 3 was admitted to the facility 09/2022 with diagnoses including depression and adult failure to thrive.  

a.  There was no documented evidence in the resident record that an initial service plan had been created for Resident 3 before move-in, with updates and changes as appropriate within the first 30-days.

b.  Review of the resident's service plan initiated 11/21/22, interviews with staff and observations of the resident showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Depression/anxiety signs and symptoms;

* Dressing assistance;

* Grooming assistance;

* Eating all his/her meals in the apartment;

* Outside services; and

* Catheter and catheter care.

The need to ensure resident service plans were completed prior to move-in, updated as needed within 30 days, accurate and provided clear direction to staff on the delivery of services was reviewed with Staff 24 and Staff 25 (Consultants) on 11/30/22. No additional information was provided.

3. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

Observations of the resident and interviews with staff from 11/29/22 to 12/01/22, review of the resident's clinical record including the most recent service plan, dated 03/14/22, showed the service plan was not reflective of the resident's current care needs and had not been reviewed quarterly as required and/or updated as needed and did not provide clear direction to staff in the following areas:

* Level of assistance needed with ADLs;

* Two-person transfer assistance;

* Use of manual wheelchair for mobility;

* Specific direction to staff when bathing assistance would be needed;

* Hospice services and schedule;

* Toileting ability and need for assistance;

* Instructions for oxygen use including flow rate;

* Instructions to staff for care of his/her dog;

* Ability to smoke safely and need for assistance; and

* Resident specific needs during an emergency evacuation.

The need to ensure resident service plans were reflective of current care needs, updated and provided clear direction to staff was reviewed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed prior to move in, reflective of the resident's needs, provided clear direction regarding the delivery of services and were followed for 4 of 5 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility on 10/02/22 with diagnoses including cerebral palsy.

Review of the resident's service plan dated 10/02/22, interviews with the staff and observations and interview of the resident revealed the service plan was not reflective of Resident 5's current care needs and/or did not provide clear direction to staff in the following areas:

* Bathing;

* Eating/Meals;

* Mental health;

* Bowel/Bladder;

* Mobility; and

* Falls.

The need to ensure resident service plans were reflective of the resident's needs, and provided clear direction to staff on the delivery of services was reviewed with Staff 24 and Staff 25 (Consultants) on 11/30/22. They acknowledged the findings.

4. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

Resident 6's service plan was reviewed, and caregiving staff and the resident were interviewed. The service plan, dated 05/14/22, was not updated following quarterly evaluations. Additionally, the service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas:

* Routine and PRN Psychotropic medications;

* Routine and PRN pain medications;

* Transfers;

* Outside providers; and

* Safety checks.

On 12/01/22, the need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 3, 4, 5, and 6 service plans will be updated after the evaluation is completed. The ABST will be updated with every service plan review. All resident service plans will be reviewed and updated.

2. A new service plan process and tool will be implemented. Consultant will train management staff on how to write service plans based on evaluation information. New service plans will be reviewed for completeness during clinical meeting. A service plan schedule will be developed and implemented. New residents will have a complete service plan developed prior to move in. Adherence to the service plan schedule will be reviewed weekly.

3. Weekly.

4. Administrator, designee.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1, 3, 4, 5 and 6's most recent service plans lacked documentation a Service Planning Team reviewed and participated in the development of their service plans.

On 12/01/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 1, 3, 4, 5, and 6 evaluations and service plans will be reviewed and updated. Service planning team involvement will be documented in the resident record. Management staff will be trained on requirements for service planning. All resident evaluations and service plans will be reviewed and updated, and service planning team involvement documented in the resident record.

2. Review of service planning team documentation will be reviewed with each service plan update.

3. Weekly.

4. Administrator.

2.  Resident 3 was admitted to the facility in 09/2022 with diagnoses including depression and adult failure to thrive.

Resident 3's progress notes, dated 09/24/22 through 11/14/22, were reviewed and revealed the following short-term changes of condition:

* 10/05/22 Returned from hospital with newly placed Foley catheter;

* 10/09/22 Blood in catheter;

* 10/10/22 Return from hospital;

* 10/10/22 Increased anxiety;

* 10/13/22 Two falls;

* 10/17/22 Returned from hospital with diagnoses including UTI;

* 10/26/22 Self reported fall; and

* 11/11/22 Blood in catheter tube and bag.

There was no documented evidence the facility evaluated the resident, determined or documented actions or interventions needed for the resident nor were the changes of condition monitored through resolution for each change of condition.

The need to ensure residents were evaluated, interventions determined and monitoring documented at least weekly through resolution was discussed with Staff 24 and Staff 25 (Consultants) on 11/30/22.  No additional information was provided.

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 the condition was monitored to resolution at least weekly for 4 of 5 sampled residents (#s 3, 4, 5 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

A review of the resident's clinical record, including charting notes and physician communications from 09/06/22 through 11/16/22, and staff interviews identified the resident experienced multiple short-term changes of condition in the following areas:

* 10/16/22 Resident sustained a skin injury;

* 10/21/22 Non-injury fall;

* 11/16/22 Resident was sent to the ER; and

* 11/18/22 New medications and discontinuation of multiple medications.

There was no documented evidence the facility consistently evaluated the resident, determined actions or interventions specific to each change of condition, updated the service plan as needed, or monitored and documented on the progress of the condition at least weekly until resolved.

The need to ensure the facility evaluated, determined and documented what actions or interventions were needed for changes of conditions and monitored until resolution was reviewed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

3. Resident 5 was admitted to the facility 10/2022 with diagnoses including cerebral palsy.  

Resident 5's progress notes and facility records dated 10/04/22 through 11/28/22 were reviewed and revealed the following:

* 10/15/22 an area "resembling pressure sore" was noted;

* 10/27/22 "redness to lower back" was noted; and

* 11/05/22 resident returned from hospital.

There was no documented evidence the facility evaluated the resident, determined or documented actions or interventions needed for the resident nor were the changes of condition monitored through resolution for each change of condition.

In an interview with Staff 9 (Resident Assistant) and Staff 13 (Agency Staff) on 11/30/22 at 11:30 am it was revealed Resident 5 had no current skin breakdown.

The need to ensure residents were evaluated, actions or interventions needed were determined and monitoring was documented at least weekly through resolution was discussed with Staff 24 and Staff 25 (Consultants) on 11/30/22. The findings were acknowledged.

4. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

Resident 6's record was reviewed and noted the following:
 

* On 08/31/22, a progress note indicated the resident had experienced weight loss and the resident's supplemental shakes were going to be increased. There was no documented evidence the facility reviewed interventions for effectiveness or monitored the change of condition until resolution.

* On 08/26/22, the resident was found on the floor from a non-injury fall. There was no documented evidence the facility reviewed previous fall interventions for effectiveness, or developed new interventions to minimize further occurrences of falls.

* On 09/25/22, the resident experienced a fall while transferring from the toilet. There was no documented evidence the facility reviewed previous fall interventions for effectiveness, or developed new interventions to minimize further occurrences of falls.

On 12/01/22, the need to ensure residents who experienced a change of condition were monitored until resolution was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 3, 4, 5 and 6 will be assessed by the RN, any changes of condition noted with follow up, and the evaluations and service plans updated. All residents will be assessed by the RN and follow up initiated as needed.

2. Licensed nurses will be trained by the consultant on change of condition and monitoring requirements, fall interventions, skin assessment and monitoring, new medication response, catheter care and UTI response, behavioral response and interventions, and weight change assessment and interventions. All staff will be trained on change of condition and monitoring by consultant. Resident change of condition will be reviewed in clinical meeting held multiple times per week by administrator, licensed nurses, and resident care coordinators. Tools for tracking change of condition and monitoring will be provided by consultant. The 24-hour book will be reviewed, redeveloped and implemented with staff training. Staff will be taught how to read and follow a TSP and to notify the licensed nurse when required. Med techs will be taught how to document.

3. Daily, weekly.

4. Administrator, licensed nurses.  

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 2 of 2 sampled residents (#s 1 and 4) who received insulin injections by unlicensed facility and agency staff. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2020 with diagnoses including diabetes and required insulin injections four times daily by unlicensed staff.

Review of the current delegation records for Resident 1 on 11/30/22 revealed no documented evidence Staff 26 (Agency MT) and 27 (MT) had been delegated for insulin administration.

Staff 24 (Consultant) reported on 11/30/22 that all delegations would be reviewed and completed as indicated. Until completed, only currently delegated staff and licensed nurses would administer insulin to the residents.

On 11/30/22, the need to ensure all staff who administered insulin injections were delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants).  They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including diabetes and required insulin injections daily by unlicensed staff.

Review of the current delegation records for Resident 4 on 11/30/22 revealed no documented evidence Staff 28 (MT) had been delegated for insulin administration.

On 11/30/22, the need to ensure all staff who administered insulin injections were delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants).  They acknowledged the findings.

1. The RN has been retrained on how to engage in and document RN delegation. All required documentation was completed.

2. A new RN will be taking over RN delegation in January 2023. The new RN will assess all residents with an RN delegated procedure and observe all med techs in the procedure of insulin administration prior to transfer of RN delegation. Consultant will oversee RN delegation transfer process. Staff will be retrained as needed for specific RN delegated procedures. All med techs will be retrained on diabetes, what insulin does to the body, and the administration of insulin. The RN delegation binder will be redeveloped and kept in the med room. Documentation will be on consultant RN delegation forms. Staff will not be scheduled to provide an RN delegated procedure until authorized in writing.

3. Weekly.

4. Administator, RN.

Based on observation, interview and record review, it was determined the facility failed to ensure outside service providers left written information in the facility that addressed the on-site services provided and any clinical information necessary for facility staff to provide supplemental care and failed to ensure recommendations from outside providers were followed for 3 of 3 sampled residents (#s 3, 4 and 6) who received outside services. Findings include, but are not limited to:

1.  Resident 3 was admitted to the facility in 09/2022 with diagnoses including depression and adult failure to thrive.

Outside provider notes dated 10/09/22 noted the resident was newly receiving services for Foley catheter care, medication education, pain control, PT and OT evaluation were also noted.

On 10/18/22 an outside service provider noted the resident had an upcoming appointment and would receive skilled nursing services for wound care and a neurological assessment.

Resident 3 was observed to have a catheter in place on 11/28/22 and had no visible wounds nor were wounds noted in the clinical record.

There was no documented evidence the recommendations were reviewed by the facility or followed up on to determine if new interventions were necessary.

Coordination of care was reviewed with Staff 24 and Staff 25 (Consultants) on 11/30/22.  No additional information was provided.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

During the acuity interview on 11/28/22, Resident 4 was identified as receiving outside provider services related to hospice.  

The resident's 03/14/22 service plan, 09/06/22 through 11/16/22 charting notes, outside provider notes, and the facility's shower schedule were reviewed.

Resident 4's shower schedule indicated the resident had not showered from 11/01/22 through 11/28/22.

During interviews with staff on 11/29/22, they confirmed there was no documentation the resident had been bathed from the facility or hospice; however, staff reported the resident had received a whirlpool bath earlier that day.

There was no documentation regarding what care the resident was receiving from hospice, whether bathing assistance was provided, and if the service plan required adjustment, and no documented evidence the facility had coordinated care regarding any supplemental care that needed to be provided.

The need to ensure outside provider care was coordinated, communicated to staff and added to the service plan was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

During the survey, Resident 6's records were reviewed, and staff were interviewed about his/her care needs. Resident 6 had been receiving home health RN, PT, and OT since February 2022.  The following were identified:

*Outside provider visit notes were not consistently being documented in the resident's record; and

*There was no documented evidence the facility had coordinated care with outside service providers regarding any clinical information needed to provide supplemental care.

On 12/01/22, the need to coordinate care with on and off-site health care providers was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 3, 4 and 6 will be assessed to ensure updated status information is provided to outside service providers and documentation regarding outside services is in the resident record. All residents will be assessed to determine if outside services would be appropriate.

2. A new process in place for where outside services can obtain the outside service form and what to do with it when it is complete. There is a new outside provider binder with sign in sheet and blank forms. The completed form will go to the med tech and will be processed similar to a new order, using the 24-hour book system. Med techs and licensed nurses will be trained on how to review, process, and document outside provider communication. Outside provider communication and follow up documentation will be reviewed in clinical meeting. TSP will be implemented and service plan updated as needed.

3. Daily, weekly.

4. Administrator, designee, licensed nurses.

Based on observation and interview, it was determined the facility failed to consistently comply with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:

Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility, except when the employee is alone in a closed room.

Observations of staff during the survey revealed multiple instances of staff working with residents who failed to wear their mask properly by covering both their mouth and nose.

On 12/01/22, the need to ensure all staff were properly wearing a face mask was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. All staff were trained in mask use expectations. A manager on duty program was implemented and management staff trained in how to coach staff to comply with mask use expectations.

2. Manager on duty program implemented for oversight, observation, and coaching of staff in proper infection control practices including mask use. All staff will be retrained in infection control.

3. Daily.

4. Administrator, designee.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to lack of delegation, following or having physician orders, notifying the prescriber related to refusing treatment, inaccurate medication records, lack of an evaluation for the residents' ability to self administer medications and lack of competency training for employees who administered medications. This constituted a finding needing an immediate plan of correction for the health and safety of residents. Findings include, but are not limited to:

During the re-licensure survey, conducted 11/28/22 through 12/01/22, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:

*C 282: RN Delegation and Teaching;

*C 301: Systems: Medication Administration;

*C 303: Systems: Medication and Treatment Orders;

*C 305:  Systems: Residents Right to Refuse;

*C 310: Systems: Medication Administration;

*C 325: Systems: Self-Administration of Medications;

*C 330: Systems:  Psychotropic Medications; and

*C 372: Training within 30 days: Direct Care Staff.

On 11/30/22 at 11:15 am the survey team requested an immediate plan of correction to address the issues identified. At 2:00 pm, a plan was received and accepted by the survey team and the immediate jeopardy was abated.

1. Pharmacy contacted for every order including VA residents. Training for all med techs on December 7-8, 2022. Self-med evaluation audit completed for all residents. Full controlled substance to MAR audit will be done. See C282, C301, C303, C305, C310, C325, C330, C372.

2. System review and correction to prevent future concerns with Consonus Pharmacy on December 27-28, 2022 (3-way audit). Exception and variances reports are reviewed multiple times per week. Order recaps will be reviewed and sent for signature. Training for all med techs on medication system needs. Clinical meetings held multiple times per week to review medication exceptions and variances. A competency checklist will be implemented and all med tech skill compentency will reviewed and training will be developed to address competency needs. New med techs will be trained and competency before being independently assigned medication related job duties.

RN will assess competence for all med techs related to RN delegation and complete documentation.

3. Daily, monthly, quarterly.

4. Administrator, designee, RN.

Based on observation and interview, it was determined the facility failed to ensure staff persons who administered medications visually observed the resident take the medication, for one non-sampled resident. Findings include, but are not limited to:

During an observation, on 11/29/22, a non-sampled resident asked Staff 11 (MT) for his/her routine medications. Staff 11 reported his/her medications were left in their room for when s/he returned.

In an interview with Staff 11, on 11/29/22, it was reported the non-sampled resident medications were placed in a disposable cup in their room until s/he had returned.

Review of the non-sampled resident record indicated there was no signed physician orders for medications to be left at bedside.  

On 12/01/22, the need to ensure medication technicians visually observed residents take their medications was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. All residents who want to self administer any or all of their medications have been evaluated, including the resident in question during survey. Information has been sent to PCPs requesting orders and/or clarification. Med techs have been trained to not leave any medication unattended in resident rooms. Med tech training was done on December 7-8, 2023.

2. Regular med tech meetings are scheduled. All resident self medication evaluations and medication orders are being reviewed. A whiteboard will be put in place with information on residents who self administer medication and date of last evaluation. Ongoing evaluations will be scheduled to occur with quarterly service plan updates.

3. Weekly.

4. Administrator, licensed nurses.

4. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure, type two diabetes, depression, and anxiety disorder.

Resident 4's physician orders and 11/01/22 through 11/28/22 MAR were reviewed and identified the following medications were not administered as prescribed due to "medication out waiting on pharmacy."

* Chlorpromazine (antipsychotic) 0.5 ml every six hours routinely was not administered on 11/01/22, 11/02/22, 11/06/22, 11/11/22, and 11/12/22;

* Haloperidol (antipsychotic) 0.5 ml three times daily for nausea was not administered on 11/01/22;  

* Guaifenesin (expectorant) 20 ml four times a day was not administered on 11/01/22 and 11/02/22;

* Novolog (insulin) inject 11 units three times daily with meals was not administered on 11/09/22, 11/11/22, and 11/13/22. The reason listed on the MAR was "too close til next dose," "could not locate resident to administer within window," and

"missed."

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

2.  Resident 3 was admitted to the facility in 09/2022 with diagnoses including depression and adult failure to thrive.

a. Review of the 11/01/22 through 11/28/22 MAR noted the following medications:

* Gabapentin one tab every eight hours for pain;

* Bactrim two times daily for seven days (for a UTI); and

* Melatonin one tablet at bedtime as needed for sleep that was administered on three occasions.

There was no documented physician order in the resident's record for the above medications being administered by the facility.

b. Physician orders dated 09/20/22 noted the following:

*Hydrocodone-acetaminophen one tablet by mouth two times daily as needed for pain; and

*Sertraline one tablet by mouth daily for depression.

There was no documented evidence the medications had been transcribed onto the MAR and administered as ordered.

Maintaining physician orders in the resident's record and following orders was reviewed with Staff 24 and Staff 25 (Consultants) on 11/30/22.  No additional information was provided.

3. Resident 1 was admitted to the facility in 01/2020 with diagnoses including insulin dependent diabetes.

Physician orders and MARs for Resident 1, reviewed from 11/01/22 - 11/28/22, revealed the following orders were not followed:

a. Insulin Aspart 17 units every evening before dinner was not given on 11/10/22, 11/12/22 and 11/19/22. Additionally, no CBG's were documented. The MAR was blank with no explanation of why the insulin was not administered or CBG checked.

b. Lantus Solostar pen 15 units nightly was not given on 11/10/22 and 11/20/22. Additionally, no CBG's were documented. The MAR was blank with no explanation of why the insulin was not administered or CBG checked.

c. SPS 60 ml solution ordered two times a week was not given on 11/19/22. Staff circled their initials indicating the medication was not administered and documented "out waiting on pharmacy."

d. Tramadol 100 mg every eight hours was not given on ten occasions between 11/01/22 and 11/28/22. Staff circled their initials indicating the medication was not administered and documented "out waiting on pharmacy" on eight occasions. Two occasions the MAR was left blank with no explanation as to why the medication was not given.  

e. Nystatin powder twice daily to affected areas was not applied on 11/10/22 PM and 11/13/22 AM. The MAR was blank with no explanation as to why the powder was not applied.

f. Vitamin D3 4000 IU every day was not given on 11/13/22 and 11/23/22.  There was no explanation as to why the medication was not given.

g. On 11/13/22, the following medications were not administered: Aspirin 81 mg, Cromolyn nasal spray, Diltiazem ER 180 mg, Ferrous Sulfate EC 325 mg, Insulin Aspart 15 units every morning, Lantus Solostar 40 units every morning, Metamucil, Sertraline 50 mg and Torsemide 20 mg. Staff circled their initials indicating the medications were not given or left blank. The MAR that had circled initials included documentation of "med out waiting on pharmacy". There was no explanation documented for the medications on the MAR left blank. Buspirone 10 mg three times daily was not administered on two of the three scheduled administration times on 11/13/22. The MAR included an explanation that the medication was available, although the staff was not trained on the paperwork for receipt of medication and had notified the RN.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants) on 11/29/22. They acknowledged the findings. No further information was provided.

Based on interview and record review it was determined the facility failed to ensure that physician's orders were carried out as prescribed and documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility on 10/02/22 with diagnoses including cerebral palsy.

In an interview with Staff 11 on 11/29/22 at 12:40 pm and review of the resident record, there was no documented evidence that written, signed physician or other legally recognized practitioner orders were available in the resident record.

On 11/30/22 at 12:07 pm, the surveyor requested staff to obtain signed physician orders for the resident. Signed orders were provided to this surveyor by Staff 25 (Consultant).  

The need to ensure written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record was discussed with Staff 24 and Staff 25 (Consultants) on 11/30/22. The findings were acknowledged.

5. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

On 11/28/22, survey requested copies of signed physician orders for all medications Resident 6 was receiving. Interview and record review indicated the facility failed to have current signed physician's orders for the following medications on the residents MAR:

*Azelastine 137mcg/0.137ml two times a day;
*Clopidogrel 75mg once a day;
*Diltiazem 120mg once a day;

*Duloxetine 60mg once a day;
*Ensure once a day;
*Flunisolide spray once a day;
*Hydralazine 10mg three times a day;
*Hydrochlorothiazide 12.5mg once a day;
*Lamotrigine 100mg twice a day;
*Levothyroxine 100mg once a day;
*Losartan 25mg once a day;
*K-Dur 10meq twice a day;
*Pravastatin 20mg once a day;
*PRN Acetaminophen 325mg;
*PRN Ibruprofen 200mg; and
*PRN Ondansetron 4mg.

On 12/01/22, the need to ensure signed physician orders were documented in resident records for all medications and treatments being administered was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 1, 3, 4, 5, and 6 orders were sent to the PCP for review. All resident orders have been reviewed by the pharmacy and sent to prescribers for review and signature. Med techs were trained in order processing, follow orders, how to respond if medication not available, when to call the licensed nurse, and documentation on December 7-8, 2022.

2, A 3-way MAR to Chart to Order audit will be done by Consonus Pharmacy on December 27-28, 2022. A new system will be implemented to review order and send to prescribers at quarterly service plan updates. All new orders will be reviewed with a 3rd check process by the licensed nurse. New orders will be placed in the 24-hour book until 3rd check process is complete. Order status will be reviewed during cinical meeting. Med techs will continue to be trained on order processing, following MAR instructions, how to respond if medication not available, when to call the licensed nurse, and documentation requirements. Medication exception and variances will be review in clinical meeting with follow up.

3. Daily, weekly.

4. Administrator, licensed nurses.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

A review of the resident's physician orders and 11/01/22 through 11/28/22 MAR identified the resident had refused medications on 13 occasions.

There was no documented evidence the physician had been notified of the refusals.

The need to ensure the facility had a system to notify the physician or other practitioner when a resident refused to consent to a medication or treatment order was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 2 of 2 sampled resident (#s 4 and 6) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

A review of the resident's physician orders and 11/01/22 through 11/28/22 MARs identified the resident had refused medications and treatments on six occasions.

There was no documented evidence the physician had been notified of the refusals.

On 12/01/22, the failure to notify physicians of the documented multiple treatment and medication refusals were reviewed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 4 and 6 prescriber will be notified of medication refusals. Med techs were trained December 7-8, 2022 on process for notifying prescriber of medication refusals and documentation.

2. All resident MARs will be reviewed for exceptions and variances and prescribers notified of refusals. A fax will be sent to each prescriber asked them if they want to be notified of medication refusals and how often. Medication exception and variances will be reviewed in clinical meeting with follow up. Med techs will continue to be trained in how to respond to medication refusals.

3. Daily, weekly.

4. Administrator, licensed nurses.

Based on interview and record review, it was determined the facility failed to ensure the MAR was complete and accurate and included resident-specific parameters for the administration of PRN medications for 2 of 6 sampled residents (#s 4 and 6 ) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

Review of the resident's 11/01/22 through 11/28/22 MAR revealed the resident had multiple bowel, pain and shortness of breath medications for each condition which lacked clear instruction to staff regarding the timing and sequence for administration of the medications.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

Review of the resident's 11/01/22 through 11/28/22 MAR revealed the resident had multiple PRN pain medications which lacked clear parameters for when staff were to administer the medications.

On 12/01/22, the need to ensure there were clear parameters for staff when administer PRN medications for the same condition was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 4 and 6 prn parameters will be updated. All resident MARs will be reviewed and prn parameters updated.

2. A new 3-check process of order review will be implemented. Orders will be placed in the 24-hour book during processing. Orders will be reviewed during clinical meeting and the RN will ensure prn parameters are in place. Med techs will be trained in how to follow prn parameters and document, including medication effectiveness.

3. Daily, weekly.

4. Administrator, RN.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications at least quarterly and obtain a physician or other legally recognized practitioner's written order of approval for self- administration of medications for 1 of 1 sampled resident (#2) who administered their own medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 12/2019.

During the acuity interview on 11/28/22, Resident 2 was identified as administering his/her own medications. Record review and interviews with staff and Resident 2 identified the following:

*An evaluation to determine Resident 2's ability to safely self-administer medications was completed on 07/21/20. There was no documented evidence of a quarterly evaluation.

*There was no documented evidence the facility obtained a written physician order authorizing the resident to self-administer their own medications.

On 11/30/22, the need to ensure the facility obtained a physician order for residents who chose to self-administer their own medications and residents were evaluated at least quarterly for their ability to safely self-administer medications was reviewed with Staff 1 (ED designee), He acknowledged the findings.

1. Resident 2 self medication evaluation will be done and orders requested from PCP for self medication if determined capable. An audit of all resident rooms will be done to observe for presence of self medications. A self medication evaluation will be completed for all residents who request to self medicate and order requests sent to PCP. Med techs will be trained in how to adminster medication and observe resident taking the medication if there is no order for self medication.

2. Residents will be screened at move in and with each quarterly evaluation for request and ability to self medicate any or all medications. Self medication evaluations will be completed and orders received from PCP if a resident requests to self medicate. A new protocol will be put in place regarding resident self medication. Med tech skill compentency related to administration of medication will be determined during orientation and quarterly.

3. Weekly, quarterly.

4. Administrator, RN.

Based on interview and record review, it was determined the facility failed to ensure the specific reasons for use for PRN psychotropic medications were included on the MAR and non-pharmacological interventions had been documented as attempted and ineffective prior to administering the medication, for 2 of 2 sampled residents (#s 4 and 6) who were prescribed and were administered PRN psychotropic medications. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure, type two diabetes, depression, and anxiety disorder.

Review of the clinical record indicated Resident 4 had orders for, and was administered, PRN clonazepam (for anxiety) on three occasions from 11/01/22 through 11/28/22. The following were identified:

* There were no specific reasons for use documented on the MAR which described how Resident 4 exhibited "anxiety"; and

* The facility failed to document non-pharmacological interventions were attempted and were ineffective prior to administering the medication.

The need to ensure there were specific reasons for use and non-drug interventions were attempted and ineffective prior to administering a PRN psychotropic medication was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.  

2. Resident 6 was admitted to the facility in 06/2019 with diagnoses including dysphagia.

The resident's 10/01/22 through 11/07/22 MARs were reviewed, and the following was identified:

* PRN Lorazepam 0.5mg every six hours for anxiety, failed to include non-pharmacological interventions for staff to attempt prior to administration of the medication and to specify how the resident exhibited signs and symptoms of anxiety.

On 12/01/22, the need to include resident-specific parameters on the MAR for PRN psychotropic medications and non-pharmacological interventions were attempted prior to administering psychotropic medications was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants). They acknowledged the findings.

1. Resident 4 and 6 PRN psychotropic medications will be reviewed by the RN and reason for use, prn parameters and non-pharmacologic interventions will be documented. Med techs will be trained in how to identify need for, and follow and document prn parameters and non-pharmacologic interventions. All resident medication orders will be reviewed for reason for use, prn parameters, and non-pharmacologic interventions. MAR content will be updated as needed.

2. A new order processing system will be implemented which includes a 3-check system, a 24-hour book, and clinical meeting. The orders will be processed by the med tech and reviewed by the RCC and licensed nurse. The RN will review for presence and completeness of prn parameters.

3. Weekly.

4. Administrator, RN.

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment was completed by an RN, PT or OT and/or was reviewed quarterly for 2 of 2 sampled residents (#s 1 and 4) who had siderails on their beds. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2020 with diagnoses to include Congestive Heart Failure and had chronic pain to the legs and feet related to edema.

On 11/29/22, Resident 1's bed was observed to have a half siderail on the wall side of the bed. The resident reported he/she used the side rail to move and reposition self when in bed.

A review of Resident 1's clinical record revealed the facility had not completed an RN, PT or OT assessment for use of the side rail.

The need to complete an RN, PT or OT assessment prior to use of an assistive device with potentially restraining qualities was discussed with Staff 1 (ED designee), Staff 24 and Staff 25 (Consultants) on 11/30/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2020 with diagnoses including congestive heart failure and type two diabetes.

On 11/29/22,observations of the resident and resident's room showed bilateral quarter-length side rails were in the up position on Resident 4's bed.

There was no quarterly assessment for the bilateral side rails completed by the RN, PT or OT for use of the assistive devices with potentially restraining qualities. There were no instructions to staff in the resident's service plan regarding the use or safety precautions of the side rails.

The need to complete assessments of supportive devices with restraining qualities at least quarterly was discussed with Staff 1 (ED designee) and Staff 24 (Consultant) on 12/01/22. They acknowledged the findings.

1. Resident 1 and 4 supportive device assessment/ evaluation will be completed by the RN. A full room audit will be done to identify resident devices in need of a supportive device assessment/evaluation. A list of supportive devices with date of most recent evaluation will be created.

2. Staff will be trained on what is a supportive device. The RN will be notified when any supportive device is ordered or obtained and an initial assessment will be completed. A list of current supportive devices will be added to the whiteboard with the date of the last assessment. Assessments/evaluations will be completed quarterly.

3. When obtained/ordered and quarterly.

4. Administrator, RN.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

During an interview on 11/29/22 with Staff 1 (ED designee) and Staff 24 and 25 (Consultants) the following was reviewed:

1. During a review of sampled resident's service plans, it was determined the ABST failed to accurately include activities of daily living and other tasks related to care due to service plans lacking updated and accurate information on resident care needs.

2.  The facility did not have a system for conducting updates of the ABST tool for each resident as required including:

(a) Before a resident move-in, with amendments as appropriate within the first 30 days to address a resident's needs;

(b) Whenever there was a significant change of condition; and

(c) No less than quarterly, preferably at the same time the resident's service plan was updated.

3.  The facility was using an ABST tool that generated daily staff hours but was not consistently staffing to the levels identified. The ABST staff level noted four caregivers and two medication aides on day shift and swing shift and three caregivers and two medication aides on the overnight shift. Review of the 11/01/22 through 11/28/22 staffing schedule revealed 62 times the facility was not staffing according to the levels identified by the ABST tool.

The ABST tool was reviewed and discussed with Staff 1, Staff 24 and Staff 25 on 11/29/22 at 3:15 pm. Staff acknowledged the findings.

1. The ABST is being updated as evaluations and service plans are updated, and with any change of condition.

2. Same as above. Staffing will be scheduled based on ABST information.

3. With any change of condition and quarterly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) prior to move-in and no less than quarterly for 4 of 6 sampled residents (#s 5, 8, 9 and 11) and multiple unsampled residents whose ABST was reviewed. This is a repeat citation. Findings include, but are not limited to:

On 08/14/23 at 3:28 pm, the ABST was reviewed with Staff 3 (RCC) and revealed the following:

a. Resident 5 was admitted to the facility in 09/2022 and his/her ABST had not been reviewed and updated quarterly since 02/01/23.

b. Resident 9 was admitted to the facility in 03/2022 and his/her ABST had not been reviewed and updated quarterly since 02/01/23.

c. Resident 11 was admitted to the facility in 08/2022 and his/her ABST had not been reviewed and updated quarterly since 02/01/23.

d. Resident 8 was admitted to the facility in 09/2022 and his/her evaluation had not been entered into the ABST.

e. The ABST for 15 unsampled residents had not been reviewed or updated quarterly.

The need to ensure the facility's ABST was updated prior to a resident's move to the facility and no less than quarterly was reviewed with Staff 29 (ED), Staff 31 (Assistant Wellness Director), Staff 24 (Consultant), Staff 45 (RN Consultant) and Staff 3 on 08/16/23. They acknowledged the findings.

1.  Request meeting with Katie Gaffney ABST Policy Analyst. At time of change of condition and quarterly ABST will be updated to reflect current care plan.

2.  Administrator and Clincial Team to review ABST.

3.  Before a resident move in, with amendments as appropriate within the first 30 days to address a resident's needs.  Whenever there is a significant change of condition.  Quarterly updates with care plan.

4.  Administator.   

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation topics and pre-service dementia training had been completed, with certification, prior to staff providing direct care to residents for 3 of 4 newly hired staff (#s 9, 17 and 22). Findings include, but are not limited to:

The facility's training records were reviewed on 11/29/22 and revealed the following:

1. Staff 9 (Resident Assistant), hired 11/02/22, Staff 17 (MT), hired 11/04/22 and Staff 22 (Culinary Assistant), hired 11/17/22 lacked documented evidence they had completed the following:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures; and

* Written job description.

2. Staff 9 (Resident Assistant), hired 11/02/22, Staff 17 (MT), hired 11/04/22 and Staff 22 (Culinary Assistant), hired 11/17/22 lacked documented evidence they had completed the following:

* Dementia disease process;

* Techniques for understanding, communicating, and responding to behaviors:

* Strategies for addressing social needs and engaging (residents) in meaningful activities; and

* Specific aspects of dementia including pain, providing food/fluids, preventing wandering, use of centered person approach.

Requirements for pre-service training were reviewed with Staff 1 (ED designee) on 11/29/22. He acknowledged the findings.

1. Staff 9, 17, and 22 will complete preservice training requirements and review/sign a job description. All staff training records will be reviewed and training assigned as determined by review.

2. A training checklist will be developed and used with every staff training record. Staff will complete preservice training prior to being scheduled for daily work duties. Consultant provided recommended Relias training courses that meet the regulatory requirement.

3. During orientation and quarterly.

4. Administrator, business office manager.

Based on interview and record review, it was determined the facility failed to have a system in place to ensure their training program included methods to determine competency of direct care staff through evaluation, observation or written testing, in caregiving and medication duties assigned for 3 of 3 newly hired staff (#s 9, 14 and 19) and 5 of 5 medication aides (4, 15, 18, 19 and 20) lacked documented medication administration competencies and were working independently with residents.  Residents' care needs were put at risk related to lack of training. Findings include, but are not limited to:

a.  Staff training was reviewed on 11/29/22 at 10:35 am. Staff 9 Resident Assistant (RA) hired 11/02/22, Staff 14 (RA) hired 05/27/22 and Staff 17 (MT) hired 11/04/22 had no documented evidence they had demonstrated competency within 30 days of hire or prior to working independently in the required areas including:

*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;

*General food safety, serving and sanitation;

*Other duties as applicable (Med pass, treatments); and

*First Aid/Abdominal Thrust.

Staff 9 and 14 were working as caregivers independently without documented evidence of training in required areas and Staff 17 was working as a medication aide and caregiver without documented evidence of required training including competency demonstration.

On 11/29/22 at 11:35 am, in an interview with Staff 1 (ED designee) and Staff 2 (Business office manager) they stated they were unable to locate any staff training records or verify the staff completed demonstrated or documented evidence of their 30 day competencies.

b.  In addition, five MT's records were reviewed to determine if they had demonstrated and documented evidence of completing med pass training within 30 days of hire. The record review showed Staff 4, hired 10/27/22, Staff 15, hired 11/08/21, Staff 18, hired 11/01/19 and Staff 19, unknown hire date, Staff 20, hired 08/18/22, did not have competency demonstration.

At approximately 2:28 pm the survey team requested an immediate plan of correction to include:

*An audit of MT employee files to determine extent of training deficiency; and

*A timeframe and schedule for the completion of training and demonstrated competency in all required areas by MT's.

A plan was submitted and accepted prior to survey leaving the building on 11/29/22.

The plan verified Staff 7 (RN interim) on 11/29/22 completed the medication pass with the swing shift MA and night shift MA on the afternoon and evening of 11/29/22.  

The need to ensure the facility had a system which included documented methods to determine competency of direct care staff through evaluation, observation or written testing, was discussed with Staff 1, Staff 2 and Staff 24 (Consultant) on 11/29/22. They acknowledged the findings.

1. Staff 4, 9, 14, 15, 18, and 19 will complete skill/ knowledge competency evaluation specific to training requirements in the first 30 days of employment. Staff 9 and 14 will complete direct care staff skill competency observation. Staff 17 will complete med tech completency observation. All staff training records will be reviewed for presence of competency evaluation. Staff will complete completency evaluation as identified by training audit. An audit of all med tech training files was completed at survey and a timeline and schedule for the completion of training and demontrated completency in all required areas by med techs was established.

2. A training record will be created for each person upon hire. A training record checklist to include competency evaluation will be included. Staff will not be scheduled to work independently without completing the competency evaluation. A training audit will be done monthly and results reported at the monthly QI meeting.

3. Weekly, monthly.

4. Administrator, licensed nurse, business office manager.

Based on interview and record review, it was determined the facility failed to ensure Fire drills were conducted in accordance with Oregon Fire Code including complete written fire drill records, alternate routes used during fire drills and staff interviewed were aware of the designated point of safety. Findings include, but are not limited to:

Fire drill and fire and life safety training records were reviewed on 11/29/22 at 03:00 pm. The fire drill records from 05/30/22 through 10/03/22 identified the following information was not documented:

* 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.

In an interview conducted 11/30/22 at 8:48 am with Staff 9 (Resident Assistant), h/she was unable to clearly state where the designated point of safety was located.

There was no documented evidence that alternate routes were used during fire drills.

The requirements for documenting fire drills, using alternate routes and staff knowledge of designated points of safety was reviewed with Staff 1 (ED designee) on 11/30/22. He acknowledged the findings.

1. Consultant will provide facility with new fire drill form to include all required elements. Fire drill is planned in December 2022.

2. Training will be provided to maintenance director on how to run and document a fire drill. A schedule of fire drills and alternating fire and life safety topics will be developed.

3. Monthly.

4. Administrator, maintenance director.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually.  Findings include, but are not limited to:

Fire drill records, from 04/30/22 through 10/03/22, were reviewed on 11/29/22.

On 11/30/22 at 9:15 am Staff 1 (ED designee) stated the facility was not providing or documenting annual instruction for residents in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 on 11/30/22. He acknowledged the findings.

1. . Consultant will provide a form for resident fire and life safety instruction to be part of the admission packet. All residents will be provided fire and life safety information and documentation completed.

2. Fire and life training instructions will be included in the admission packet. Staff engaged in the admission process will be trained on how to provide instruction. Completed admission packets will be audited after each move in. A checklist will be developed to go with every resident move in for process elements.

3. At each admission and annually.

4. Administrator, maintenance director.

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 Department. Findings include, but are not limited to:

Refer to C 361.

1.  Review ABST on an ongoing basis to satisfy C361.

Based on observation and interview, the facility failed to ensure that toxic materials were properly labeled and stored. Findings include, but are not limited to:

A tour of the facility was completed on 11/29/22. There were multiple storage closets (end of hall by room 233, next to laundry room on second floor and next to room 113) that were unlocked and contained toxic materials.

In an interview with Staff 1 (ED designee) on 11/29/22 at 1:45 pm, he stated that the closets should be locked.

The need to ensure the facility properly labeled and stored toxic materials was discussed with Staff 1. He acknowledged the findings.

1. Staff have been trained to lock all storage closets. Toxic materials were removed and stored in a secure area. The secure storage of toxic materials and need to lock the storage closets will be reviewed again with staff at the all-staff meeting the last week of December 2022.

2. The administrator and maintenance director will do walk throughs of the community to ensure storage closets are secured and toxic materials stored appropriately.

3. Daily, weekly.

4. Administrator, maintenance director.

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

Observations of the facility on 11/29/22 revealed the following areas were in need of cleaning or repair:

* Scrapes, gouges and paint missing on wood door frames for rooms 207, 208, 209, 211, 313, 319, exit door in hallway next to room 209 and interior door of room 238;

* Chairs in third floor library, third floor pool room and in lobby near elevator had stains;

* Scrape/gouge on wall outside room 236;

* Back row of movie chairs on third floor had stains;

* Discoloration, missing paint on baseboard next to staff delivery entrance to office;

* The linoleum in first floor laundry room was cracked, peeling and an uncleanable surface.

The areas in need of cleaning and repair were discussed with Staff 1 (ED designee) on 11/29/22. He acknowledged the findings.

1. Repairs for scrapes, gouges and painting is in process. The chair in the third floor library and movie chairs will be cleaned or replaced. The linoleum in the first floor laundry room will be replaced. A full environmental audit will be done to determine any concerns and a plan developed for repairs/furniture cleaning or replacement.

2. Administrator and maintenance director walkthrough of the community. A checklist of projects in process will be created and reviewed regularly.

3. Daily, weekly.

4. Administrator, maintenance director.