The findings of the re-licensure survey, conducted 02/13/23 through 02/16/23, 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 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 first re-visit to the re-licensure survey of 02/16/23, conducted 07/31/23 through 08/01/23, 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 interview and record review, it was determined the facility failed to ensure quarterly evaluations were the foundation used to develop residents' quarterly service plans, included documented change of condition updates and were relevant to the residents' needs and current condition for 2 of 5 sampled residents (#s 1 and 4) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2022 with diagnoses including congestive heart failure (CHF).

The resident's most recent evaluation dated 12/15/22, service plan dated 12/12/22, and Temporary Plans of Care dated 10/29/22 to 12/21/22 were reviewed. The following was revealed:

* Resident 4 experienced a significant change of condition related to his/her CHF diagnosis which resulted in a 24 pound weight gain followed by a 28 pound weight loss. This change was triggered on 11/04/22;

* A change of condition evaluation was completed on 12/15/22 related to the resident's significant weight loss;

* The evaluation, dated 12/15/22, did not include information relevant to the resident's lower extremity edema; and

* The service plan was dated 12/12/22, each service area was updated on 10/26/22, and the evaluation occurred on 12/15/22. Therefore, the evaluation was not the basis of the resident's service plan.

The facility failed to ensure the evaluation was the foundation of the service plan, included documented change of condition updates and was relevant to the needs and current condition of the resident.

The need to ensure the quarterly evaluation was the foundation used to develop the resident's service plan, included documented change of condition updates and was relevant to the needs and current condition of Resident 4 was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings, and no additional information was provided.

2. Resident 1 was admitted to facility in 05/2022 with diagnoses including pressure ulcer and cerebrovascular disease.

Resident 1's service plan was dated 12/12/22, each service area was updated on 10/25/22 or 10/26/22, and the evaluation occurred on 01/19/23. Therefore, the evaluation was not the basis of the resident's service plan and contained inaccurate or incomplete information in the following areas:

* Responsive behaviors;

* Private caregiver support;

* Fall history;

* Fall reduction plan;

* Medication assistance;

* Self medication evaluation;

* Blood thinning medications;

* Topical medications;

* Skin integrity; and

* Outside providers.

The need to ensure quarterly evaluations contained sufficient and/or accurate information and were used as the basis of the quarterly service plan was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings. No additional information was received.

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

Residents 1 and 4 have been reassessed and the service plan was updated to reflect complete and accurate Resident care needs.

Prior to the resident move-in Health and Wellness Director and General Manager will review the evaluation and service plan to ensure it reflects all evaluation elements. Evaluations will be reviewed 30 days after the initial move-in and quarterly.

Evaluation training was held by H&W Director and Operations Director. Evaluation will be audited by Health and Wellness Director, RN, and General Manager quarterly.

4. Resident 4 was admitted to the facility in 03/2022 with diagnoses including congestive heart failure and chronic obstructive pulmonary disease.

The resident's current service plan, dated 12/12/22, was reviewed, observations were made, and interviews were conducted between 02/13/23 and 02/15/23. Resident 4's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Edema and interventions around edema;

* Oxygen liters per minute, strategies to increase oxygen levels, where to obtain equipment and how to manage concentrator and portable oxygen machine; and

* Use of a four-wheeled walker versus two-wheeled walker.

The need to ensure service plans were reflective of the identified needs of the resident and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings.

2. Resident 1 was admitted to facility in 05/2022 with diagnoses including pressure ulcer and cerebrovascular disease.

Resident 1's most recent service plan available to staff, dated 12/12/22, was reviewed and interviews with caregiving staff were conducted on 02/15/23. The service plan was not reflective of the resident's needs, did not provide clear direction regarding the delivery of services and did not include a written description of who shall provide the services and what, when, how, and how often the services shall be provided in the following areas:

* Bathing;

* Fall risk and interventions;

* Skin interventions;

* Outside provider services;

* Scheduled pain medications;

* Self administration of medications;

* Blood thinning medications;

* Mobility devices currently used;

* Sleeping habits;

* Assistance required for: transfers, ambulation, dressing, and toileting and/or continence care;

* Type of assistance needed for dining;

* Behaviors and interventions needed;

* Pain interventions; and

* Private caregivers.

On 02/16/23, the need to ensure the service plan reflected the resident's needs, provided clear direction regarding the delivery of services and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status and provided clear direction to staff for 4 of 6 sampled residents (#s 1, 3, 4, and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 06/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), angina and prostate cancer.

Review of the resident's service plan, dated 12/13/22, progress notes, dated 11/13/22 through 02/13/23, Temporary Plan of Care documents, incident reports, and weight records revealed the following:

Resident 6's service plan, dated 12/13/22, was not reflective or lacked clear direction to staff in the following areas:

* Elopement, including interventions to prevent reoccurrence; and

* Weight loss, with specific instructions for staff.

On 02/16/23 the need to ensure service plans were reflective of current needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings. No further information was provided.

3. Resident 3 was admitted to the facility in 05/2020 with diagnoses including edema and heart failure.

Resident 3's most recent service plan, dated 01/13/23, was reviewed, and interviews with caregiving staff and the resident were conducted. The service plan was not reflective of the resident's current status and/or lacked clear instructions to staff in the following areas:

* Weight changes; and

* Alcohol consumption.

On 02/16/23, the need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

1. Residents 1, 3, and 6 have been evaluated and service plans have been updated and are now reflective of the resident's current status. The service plans provide clear direction to staff on how to appropriately manage the concerns listed in the C260 section of the Statement of Deficiencies.

2. Staff training was conducted to review service plans, H&W Director will provide the training needed depending on assessments and evaluations.

3. H&W Director will provide Quarterly assessments and update services as needed.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to evaluate residents with a significant change of condition and refer to the facility nurse for 1 of 3 sampled residents (# 6)  who was reviewed for weight changes. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 06/2019 with diagnoses including hypertension, chronic obstructive pulmonary disease (COPD) and neuropathy.

Review of the resident's progress notes, dated 11/13/22 through 02/13/23, weight records and service plan indicated Resident 6 experienced the following change of condition:

* 10/04/22 - 247.8 pounds;

* 11/01/22 - 245 pounds;

* 12/01/22 - 219.2 pounds;

* 01/01/23 - 210 pounds; and

* 02/14/23 - 214.6 pounds.

Resident 6's weight records noted on 12/01/22 - a weight loss of 25.8 pounds had occurred in thirty days. The resident's weight decreased from 245 pounds on 11/01/22 to 219.2 pounds on 12/01/22. This equated to 10.5 %  loss of the resident's total body weight in one month and constituted a severe weight loss.

Meal observations of Resident 6 were made during lunch on 02/13/22 and 02/14/22. In both instances, the resident was observed to eat 100% of his/her meal, and required no cueing or assistance.

In an interview on 02/14/23, Resident 6 stated the "food is great here", s/he feels "pretty healthy", and further stated s/he had wanted to lose weight. The service plan instructed staff to cue and encourages the resident to eat during meal times, and indicated the resident was admitted to hospice on 12/12/22.

In an interview on 02/16/23, Staff 4 (Health and Wellness Nurse) stated s/he was aware of Resident 6's severe weight loss, which was identified on 12/01/22. Staff 4 acknowledged no interventions had been developed or implemented, to prevent further weight loss.

Resident 6 experienced a significant change of condition related to weight loss and there was no documented evidence the facility evaluated the weight loss, or determined specific actions or interventions needed in response to the weight loss. During survey, the resident's weight was measured at 214.6 pounds, showing some additional loss.

On 02/16/23, the need to ensure actions or interventions were documented in the resident's record and communicated to staff was discussed with Staff 1 (Administrator), Staff 2 and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

1. Resident 6 has been reassessed and service plans updated to reflect their needs.

2. Community staff have received training related to documenting reportable conditions and the provision of unscheduled services. Reportable conditions generate incident reports that are reviewed by the GM and HWM. The HWM/designee reviews community "dashboards" on a daily basis to address unscheduled services and service omissions that may indicate a change of condition. Service Planning and Significant Change of Condition training were conducted by H&W Manager with current staff with service planning responsibilities. Temporary service plans will be in place when needed. The HWM will ensure the RN is notified of the need for Change of Condition assessments and the service plan will be updated as needed. Service plans will be audited by Health and Wellness Manager using the CBC service plan audit tool for all future changes in conditions.

3. On an ongoing basis, the GM and HWM will have a weekly 1:1 meeting to review assessments and service plans.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely and included documented findings, resident status and interventions made as a result of the assessment for 3 of 4 sampled residents (#s 1, 4 and 6) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including a pressure ulcer.  

The resident's progress notes, dated 11/13/22 through 02/10/23, Temporary Plans of Care, dated 12/26/22 through 02/12/23, and fax communication to and from the resident's Adult Nurse Practitioner were reviewed and revealed the resident was identified as having a Stage 2 pressure wound on his/her buttocks on 12/26/22.

There was no documented evidence the RN had assessed the pressure wound with documented findings, resident status, and interventions made as a result of this assessment.

The need to to ensure an RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. No additional information was received.

3. Resident 6 was admitted to the facility in 06/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), hypertension and neuropathy.

The resident's service plan, dated 12/13/22, progress notes, dated 11/13/22 through 02/13/23, Temporary Plan of Care, and weight records were reviewed.

The weight records revealed the following:

* 10/04/22 - 247.8 pounds;

* 11/01/22 - 245 pounds;

* 12/01/22 - 219.2 pounds;

* 01/01/23 - 210 pounds; and

* 02/14/23 - 214.6 pounds.

On 12/01/22 the resident was identified with a 25.8 pound weight loss in thirty days. This equated to 10.5% of the resident's body weight, and constituted a severe loss and a significant change of condition, requiring an RN assessment.

On 02/13/23 the surveyor requested documentation of an RN assessment for the significant change. The document presented was dated 12/13/22, which was twelve days after the weight loss was identified. This assessment was not conducted timely.

On 02/16/23, the need to ensure an RN assessment was conducted timely for any significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including congestive heart failure.

Resident 4's weight records were reviewed and revealed the following:

* 10/08/22 - 221.2 pounds;

* 11/04/22 - 245.2 pounds; and

* 12/04/22 - 223 pounds.

From 10/08/22 to 11/04/22, Resident 4 had a weight gain of 24 pounds or 10.85% of his/her body weight in one month. Additionally, from 11/04/22 to 12/04/22 the resident had a weight loss of 22.2 pounds or 9.05% of his/her body weight in one month. Both weight fluctuations indicated a significant change of condition and required an RN assessment.

RN assessments for both significant changes of condition were requested on 02/14/23. The facility provided a change of condition evaluation dated 12/15/22 regarding the resident's weight loss completed by Staff 20 (Health and Wellness Nurse/LPN). On 02/14/23 at 2:11 pm, Staff 4 (Health and Wellness Nurse) confirmed she did not complete an RN assessment for the change of condition.

There was no documented evidence the facility RN completed an assessment of Resident 4's significant weight gain or weight loss.

The need to ensure all significant changes of condition were assessed by an RN and were completed in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 on 02/16/23. They acknowledged the findings, and no additional documentation was provided.

1. Residents 1, 4, and 6 were reassessed for Significant Change of Condition by RN, and service plan was updated to reflect this.

2. The HWM provided training to staff regarding "change of condition" incident reporting requirements, including weight variances and notifications to the resident's health care practitioner for potential intake monitoring orders or other orders. To ensure the violation will not happen again,- HWM, RN, and Care Coordinators who are responsible for these functions will be oriented to these practices and such training will be documented.

3. HWD/HWM will review "dashboards" and incident reports daily.  Any significant changes in condition will have assessments and service plan updates completed within 48 hours. The ongoing, weekly GM 1:1 meetings with the HWM and HWD will include a review of incident reports, assessments, and service plans. IR would be generated, resulting in HWM/GM review within 24 hours and notification of RN to complete the assessment.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, staff were informed of new interventions and the service plan was adjusted if necessary and reporting protocols were in place for 1 of 2 sampled residents (# 1) who received outside services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including cerebrovascular disease and arthritis.

Resident 1's outside provider notes, dated 01/25/23 through 02/10/23, were reviewed during the survey and revealed the following recommendations:

* 10/25/22 - "Transport chair is great to have [him/her] up in. If [patient] can have [medications] before session to [decrease] pain, [s/he] may participate better;" and

* 02/02/23 - "Safe set up for [Licensed] PT for transfers [with] arm rest removed."

Resident 1's 01/01/23 through 02/13/23 MAR was reviewed and revealed PRN pain medications, including acetaminophen and hydrocodone-acetaminophen were available for use.

In an interview with Staff 5 (Health and Wellness Coordinator) at 11:49 am on 02/15/23, she stated outside provider recommendations were triple checked and stamped before recommendations were distributed to staff on a dry erase board in the medication room.

There was no documented evidence staff were informed of new interventions and the service plan adjusted to ensure continuity of care.

The need to ensure the facility coordinated care with outside providers in order to ensure the continuity of care, staff were informed of new interventions, the service plan was adjusted if necessary and reporting protocols were in place was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings.

OAR 411-054-0045  (2) Res Hlth Srvc: On- and Off-Site Health Srvc  

1. Resident 1 has been reevaluated, and the service plan has been updated to reflect the resident's current needs along with home health recommendations.

2. HWD/HWM have trained coordinators to request all notes from Home Health during their visit, if unable to obtain they will call HH to obtain notes. They have also been trained as to when to reach out to HH in regards of HH angency not givng community needed information.

3. Home Health/Outside Provider notes will be reviewed biweekly by RN and Health and Wellness Director during clinical meetings and recommendations will be updated in service plan as needed.

4. Coordination of Care training was provided by Health and Wellness Director.

5. Service Plans will be audited quarterly to ensure HH recommendations are incorporated and updated in service plans.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied 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 was alone in a closed room.

Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth.

The need to ensure staff wore face masks properly was reviewed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings.

OAR 411-054-0050 Infection Prevention and Control

1. Infection prevention control and protocols have been established to promote a safe, sanitary, and comfortable environment along with preventing development/transmission of communicable disease.

2. An appointed Infection Control Specialist has been appointed (The General manager) and has completed all reqired elements to have this responsibility.

3. Infection Prevention Control Protocols have been established and are accessible to all staff.

4. Facility staff have been trained on all PPE usage, including masking requirements. These requirements have been maintained by all department heads.

5. During the hiring process, potential staff are required to show proof of COVID vaccination or give a written documentation of religious or medical exemption. Employee files were gone through and udated according to the policy.

4. Resident 6's MARs, dated 01/01/23 through 02/13/23, and current physician orders were reviewed during survey. The following was identified:

The MARs lacked clear instructions for staff regarding the sequential order of use for the following PRN medications:

* Acetaminophen, hydromorphone, and naproxen were prescribed for pain;

* Albuterol, hydromorphone, and oxygen were prescribed for shortness of breath;

* Hydrocortisone cream and hydroxyzine were prescribed for pruritis (itching); and

* Milk of Magnesia and bisacodyl suppository were prescribed for constipation.

On 02/16/23, the need to ensure resident MARs were accurate and included specific instructions to staff was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, contained reasons for use and had resident specific parameters and instructions for PRN medications for 4 of 5 sampled residents (#s 1, 3, 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1's 01/01/23 through 02/13/23 MAR was reviewed and revealed the following:

* Latanoprost (eye drops) and levobunolol (eye drops) were missing reasons for use; and

* PRN acetaminophen and hydrocodone-acetaminophen lacked resident specific parameters or instructions to direct non-licensed staff on which PRN medication should be administered and in what order.

In an interview with Staff 5 (Health and Wellness Coordinator) at 1:25 pm on 02/15/23, she acknowledged the missing reasons for use and lack of parameters and clear instructions to staff for PRN pain medications.

The need to ensure medications had a reason for use, resident specific parameters and clear instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings.

2. Residents 3's physician orders and 01/01/23 through 02/13/23 MAR was reviewed during the survey and revealed the following:

* Resident 3 was prescribed PRN acetaminophen 500 mg every eight hours as needed for pain and oxycodone 5 mg every 12 hours as needed for pain. There were no directions for unlicensed staff on which pain medication to administer first.

On 02/16/23, the need to ensure there were clear parameters for unlicensed staff when administering medications was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

3. Residents 5's physician orders and 01/31/23 through 02/13/23 MAR was reviewed during the survey and revealed the following:

* Resident 5 was prescribed PRN ibuprofen 600 mg every eight hours as needed for pain, oxycodone 5 mg every six hours as needed for pain, and phenazopyridine 100 mg three times a day as needed for pain. There were no directions for unlicensed staff on which pain medication to administer first.

On 02/16/23, the need to ensure there were clear parameters for unlicensed staff when administering medications was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

1. Residents 1, 3, 5, and 6 have been reevaluated and their medication records have been updated to reflect all things outlined in the C310 section of the Statement of Deficiencies.

2. MTs have been re-trained to properly document in the MAR as to why medications or treatments were missed or refused and proper steps to take following medications being refused or held.

3. MTs have been re-trained on proper documentation and protocol to obtain medication within 24 hours from order, if unable to obtain HWD to be notified.

4. Missed medications and treatments will be reviewed daily during the clinical meeting by Health and Wellness Director and RN.

5. Proper parameters have been updated and are resident specific and provide instruction for staff. HWD and GM will conduct a monthly audit of the medication adminsitration system that is included during the time of the cycle fill audit.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including chronic obstructive pulmonary disease (COPD).

The resident's 01/01/23 through 02/13/23 MARs, prescriber's orders and evaluation, dated 12/15/23, were reviewed and revealed the Combivent Respimat inhalation spray (for COPD) was kept at bedside.

Resident 4's quarterly evaluation stated all medications were to be administered by the facility and the resident was unable to safely administer medications without assistance.

On 02/14/23 at 11:39 am, Staff 4 (Health and Wellness Nurse) confirmed there was no evaluation related to the self-administration of the resident's inhaler.

There was no documented evidence the resident was evaluated on the ability to safely administer the medications.

The need to ensure residents who administer their own medications were evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 on 02/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medication upon move-in and at least quarterly thereafter and failed to have a physician or other legally recognized practitioner's written order of approval for self-administration of medication for 3 of 4 sampled residents (#s 1, 4 and 5) who self-administered medication. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including arthritis and neuropathy. The resident's 01/01/23 through 02/13/23 MARs, prescriber's orders and evaluation dated 01/19/23 were reviewed and revealed the following five medications were approved by the prescriber to "may self administer."

* Culturelle capsule (supplement);

* Calendula cream (for comfort);

* Diclofenac sodium 1% gel (for pain);  

* Pain relieving CREA (for foot discomfort); and

* Vicks Vaporub ointment (for congestion).

Resident 1's quarterly evaluation, dated 01/19/23, stated that all medications were to be administered by the facility and that s/he was unable to safely administer medications without assistance.

An interview on 02/15/23 at 1:25 pm, Staff 5 (Health and Wellness Coordinator) confirmed there was no evaluation related to self-administration of his/her medications.

There was no documented evidence the resident was evaluated on the ability to safely administer the medications.

The need to ensure residents who administer their own medications were evaluated quarterly was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse) on 02/16/23. They acknowledged the findings.

3. Resident 5 was admitted to the facility on 01/30/23 with diagnoses including Parkinson's disease.

On 01/30/23 and 01/31/23, Resident 5's MAR was noted as the resident self-administering his/her own medications. In an interview with Staff 5 (Health and Wellness Coordinator) on 02/14/23, it was confirmed Resident 5 had administered his/her own medications on 01/30/23 and 01/31/23.

Record review of Resident 5 revealed the following:

* No physician's order regarding self-administration of his/her medications; and

* No evaluation of the Resident 5's ability to safely administer his/her own medications.

On 02/16/23, the need to ensure residents who administer their own medications had written approval by a physician or other legally recognized practitioner and residents who choose to self-administer their medications must be evaluated upon move-in was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds

1. Current Physician's Order reflecting self-administration guidelines and approval have been received for residents 1, 4, and 5.

2. Self-Administration orders will be reviewed during initial evaluation by Health and Wellness Director, RN, and General Manger.

3. H&W Director and GM will be responsible for quarterly audit to ensure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT or OT prior to use for 1 of 1 sampled resident (#3) who had side rails on his/her bed. Findings include, but are not limited to:

Resident 3 was observed during the survey on 02/13/23 through 02/16/23 and noted to have side rails attached to his/her bed in the up position.

Review of the resident's clinical record revealed the following:

* No documented evidence Resident 3 requested or approved of side rails being used and was informed of the risks and benefits of the side rails;

* No documented evidence of an assessment completed by an RN, PT or OT for the use of the side rails;

* No documented evidence other less restrictive alternatives had been attempted prior to use; and

* There was not clear instruction to caregivers on the correct use and precautions related to the use of side rails.

On 02/16/23, the lack of an assessment and documentation of requirements for side rail use was discussed with Staff 1 (Administrator), Staff 2 (Administrator) and Staff 4 (Health and Wellness Nurse). They acknowledged the findings.

1. Resident 3's service plan was updated to reflect the supportive device use and precautions. An assessment was conducted by RN and orders for supportive devices were received.

2. A community audit has been performed to ensure knowledge of all assistive devices and implementation of Physician's orders for devices, RN assessments, and updated service plans that list uses/precautions. The GM and HWM have received training related to the outside provider coordination of care requirements requiring orders and service agreement provisions for residents admitted to a hospice program.

3.The ongoing, weekly GM 1:1 meetings with the HWD  will include a review of service plans/coordination with third party providers.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled direct care staff (#s 12, 14 and 16) completed pre-service orientation and approved pre-service dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 02/13/23.

Staff 12 (Resident Assistant I) hired on 11/29/22, Staff 14 (Resident Assistant I), and Staff 16 (Resident Assistant I) all lacked documentation of pre-service orientation including:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard Precautions for infection control;

* Fire safety and emergency procedures;

* Dementia disease process;

* Techniques for understanding dementia; and

* Providing meaningful activities for dementia.

The need to ensure documentation of all completed training was available for inspection was discussed with Staff 1 (Administrator) and Staff 19 (Business Office Manager). They acknowledged the lack of documentation of the completed training.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1. Staff 12, 14, and 16 have received the proper training and orientation outlined in the C370 section of the Statement of Deficiencies.

2. All new staff will complete pre-service orientation at the time of new hire paperwork conducted by the HWD and GM.

3. Health and Wellness Director will be required to show compliance with completion of pre-service training prior to permitting staff to shadow and conduct hands on training for care.

4. Health and Wellness Director and GM will use checklist to document staff competency within 30 days of hire and review onbarding and continuing ed needs on a weekly basis during the 1:1scheduled meetings.  

5. General Manager will provide additional oversight and review all new staff training records before adding to schedule.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 direct care staff (#s 9 and 15) reviewed for staff training had completed First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 02/14/23 and revealed no documented evidence Staff 9 (Resident Assistant I), hired on 06/08/22, and Staff 15 (Resident Assistant I), hired on 09/09/22, had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 19 (Business Office Manager) on 02/14/23 and with Staff 1 (Administrator) on 02/15/23. They acknowledged the findings.

1. Staff 9, 15, and 19 have completed the required training; a note has been made in the respective files that is was after the required 30-day period. All staff records have been audited for the required training. Should other records be found in violation, the GM will document the deficient practice and ensure training is obtained if it has not been completed.

2. The GM and hiring managers (Department Heads) will use the Onboarding Checklist to ensure employees receive required training within the specified time frames.

3. The GM and hiring managers will review onboarding records at their respective weekly 1:1 meetings.

4. Hiring managers are responsible for ensuring new employees meet the conditions of employment or are removed from the work schedule. The GM is responsible for ensuring employees who have not met the conditions of employment are removed from the schedule and/or terminated.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 17 and 18) whose training records were reviewed. Findings include, but are not limited to:

Facility staff training records were reviewed on 02/14/23 and revealed the following:

Training records for Staff 17 (Resident Assistant I), hired 06/24/2019, Staff 18 (Resident Assistant I), hired 10/26/2020, did not have documented evidence of completing 12 hours of required in-service training, including six hours relating to the care of residents with dementia.

The need to ensure staff completed the required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) and Staff 19 (Business Office Manager) on 02/15/23. They acknowledged the findings.

OAR 411-054-0070 (6-7) Annual Training and Other Requirements

1. Staff 17 and 18 have completed the required in-service training for direct care staff on Relias.

2. GM and HWD will use Relias annual training assignment reports and schedule/identody training time on employee work schedules to ensure the training is completed in the required time frame.

3. Relias records will be audited quaterly by Health and Wellness Director and GM during the 1:1 weekly meetings.

4. The GM is responsible for making sure all staff meet required training.

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

Review of fire drill and fire and life safety records for 09/2022 through 02/2023 identified the following:

* There was no documented evidence fire and life safety instruction for staff had been conducted and documented on alternate months; and

* The facility had not documented residents being relocated or evacuated during fire drills, so there was no documentation of the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, the evacuation time period needed, and number of occupants evacuated.

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Administrator) on 02/15/23 at 11:10 am. She acknowledged the findings.

1. The violation cannot be corrected as it occurred in the past.

2. The GM and Plant Operations Supervisor have been re-oriented to the requirements of this regulation, the policy established for the community, and the community's fire drill documentation tool.

3. The Plant Operations Supervisor will ensure fire drills are scheduled using TELS, the community's electronic building systems management platform. The system sends notifications to both the Plant Operations Supervisor and GM to ensure they are aware the drills and training are due. The GM and Plant Operations Supervisor will review the required documentation after each drill to ensure the required elements are included.

4. The GM is responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility lacked documentation general fire and life safety requirements for residents were met. Findings include, but are not limited to:

Fire and life safety records from 08/2022 through 02/2023 were reviewed on 02/13/23.

The facility lacked documentation residents were instructed on fire and life safety procedures (including in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building) at least annually after admission.

In an interview on 02/14/23, Staff 1 (Administrator) acknowledged the lack of documentation that residents were provided fire and life safety training annually.

OAR 411-054-0090 Fire Life and Safety

1. Fire and evacuation plans are assessed and documented as part of each resident's assessment and service planning process and will serve as documentation of the review of safety procedures. During the community's fire and emergency drills, should a resident fail to follow the instructions, it will be documented and his/her needs will be re-assessed. Reviews will occur in conjunction with each evaluation.

2. GM is responsible for overall compliance. HWD and Plant Ops will review results of monthly fire drills and other required drills during 1:1 meetings.