The findings of the re-licensure survey, conducted 03/29/22 through 03/31/22, 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 Departments rules that was likely to cause a resident serious harm. An immediate plan of correction was requested in the following area:

OAR 411-054-0065 (1) Administrator Requirements.

OAR 411-54-0070 (a) (g) Staffing Requirements and Training.

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 on 03/31/22, conducted  09/19/22 through 09/20/22, 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 03/31/22, conducted on 01/12/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004

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

During the re-licensure survey, conducted 03/29/22 through 03/31/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

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

OAR 411-054-0065 (1) Administrator Requirements.

OAR 411-54-0070 (a) (g) Staffing Requirements and Training.

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.

OAR 411-054-0065 (1) Administrator Requirements. OAR 411-54-0070 (a) (g) Staffing Requirements and Training.

1.The facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility.

2. The facility put an immediate plan of correction in place during the survey and the situation was abated. 2.a) Refer to deficiencies in the report

3.The correction will need daily and monthly evaluations to ensure residents health and safety .

4.The administrator will be responsible for all corrections are completed and monitored.

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

A tour of the facility conducted on 03/30/22 identified the following required posting were not in place:

* The name of the administrator or designee in charge; and

* The facility staffing plan.

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

C152 OAR 411-054-0025 (5) Facility Administration: Required Postings

1 (a). The most current survey will be posted and available for view in the common area located in front of the business office.

1 (b).The facility staffing plan will be posted in an accessible and conspicuous location by the dining area.

1 ( c ) The Informational board was rearranged on 7/2/21 in an orderly manner, the Ombdusman poster was uncovered to reveal the entire posting.

2 (a) The administrator/interim administrator will be trained on the importance of accurate postings and provided with a copy of the Oregon Administrative rules and regulations for reference.

2 (b) The administrator/interim administrator will be trained on how to fill out the facility staffing form, the importance of accurate postings and provided with a copy of the Oregon Administrative rules and regulations for reference.

2 ( c ) The administrator/interim administrator will be inserviced on the importance of ensuring the Ombdusman poster is available for all residents in a central location and in full view and proved with a copy of the Oregon Administrative rules and regulations for reference.

3. Facility required postings system audit will be reviewed at least monthly, and postings will be reviewed daily to ensure accuracy and verify required information is readily visible to the Residents and public.

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

Based on observation, interview, and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services and resident outcomes. Findings include, but are not limited to:

Staff 1 (Administrator) was asked about the facility's quality improvement program on 03/30/22. During the interview, Staff 1 stated the facility did not have a Quality Improvement Program due to the lack of leadership oversight of the facility.

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

OAR 411-054-0065 (1) Administrator Requirements.

OAR 411-54-0070 (a) (g) Staffing Requirements and Training.

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

The need to ensure the facility had an effective method to evaluate services, resident outcomes and resident satisfaction was discussed. Staff 1 acknowledged the findings.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

1.The facility will develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction. The facility has put an immediate plan of correction in place during the survey and the situation was abated.

2.The quality improvement program will be monitored and revised as needed per resident and audited monthly.

3.Monthly audits and educationals for imroved ideas for quality improvement.

4. The administrator is responsible to see that all corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

During the survey, conducted 3/29/22 through 3/31/22, multiple Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility.

Observations made during the survey from 03/29/22 through 03/31/22 revealed the following:

During an observation on 03/29/22, the common area restrooms were without hand soap and paper towels.  During a later observation on 03/31/22, staff had replaced the roll of paper towels.

On 03/30/22 at approximately 6:30 am, the Surveyor entered the facility and observed Staff 4 (Universal Worker) and Staff 6 (Universal Worker) not wearing masks. The Surveyor asked Staff 4 and 6 to put on a face mask. Staff 4 and 6 immediately put on surgical masks.

On 03/30/22, Staff 4 (Universal Worker) let the surveyor into the building and was unsure if the facility was still screening visitors. Staff 4 created a screening sheet with visitor temperature, if the visitor was experiencing any signs or symptoms of COVID and if they had been in contact with anyone who had tested positive for COVID.

On 03/30/22, the surveyor witnessed Staff 4 exit room 2 wearing gloves and entered the kitchen wearing the same gloves. The surveyor asked Staff 4 if she had provided resident care using the gloves she currently had on and Staff 4 confirmed she had. The surveyor asked Staff 4 to immediately discard the soiled gloves and wash her hands.

On 03/30/22, Staff 3 (Universal Worker) was observed providing resident care to multiple residents then went in the kitchen to cook lunch without wearing an apron. A surveyor asked Staff 3 if there were aprons to wear during cooking and meal service times. Staff 3 located an apron and wore it during the lunch period. After meal service, Staff 3 did not take off the apron and provided ADL care to residents while wearing the apron. Staff 3 was asked to doff the apron in the soiled utility room.

On 3/30/22 soiled bed linens were observed directly on the floor of a resident room.

Multiple resident bathrooms were noted without hand soap and paper towels.

The failure to ensure universal workers consistently utilized universal precautions was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings. No further information was received.

Refer to C 530

C 160 OAR 411-054-0025  Reasonable Precautions

1.Staff will be provided with training on infection control pratices. The cleaning and storage of eye protection, including face shields, goggles, proper placement of masks, and Covid 19 guidelines to ensure following proper infection control pratices.

2. Staff will be trained on infection control precautions, plus adequate storage and disinfection practices for eye protection including face shields and goggles during orientation. Training will include proper placement of masks and Covid 19 guidlines. Competencies will be assessed during orientation and periodically there after. A review of infection control protocol will be part of each staff meeting.

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

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

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. This is a repeat citation. Findings include, but are not limited to:

Observations made during the survey from 09/19/22 through 09/20/22 revealed the following:  

On 09/19/22, Staff 3 (Universal Worker) who assisted residents with care, including toileting and incontinence care, did not wear an apron during meal service. A surveyor requested Staff 3 wear an apron to serve meals.  Staff 3 located an apron and wore it during the lunch period.

On 09/20/22, Staff 10 (Universal Worker), who assisted residents with care, including toileting and incontinence care, was observed preparing and serving breakfast. Staff 10 did not wear an apron for the meal preparation and service.

The failure to ensure universal workers consistently utilized universal precautions was discussed with Staff 1 (Administrator) and Staff 8 (Administrator designee) on 09/19/22 and 09/20/22. They acknowledged the findings.

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

1.Staff will be provided with training on infection control practices. Training will include the proper procedure for wearing aprons when preparing and serving meals/food items to ensure all staff are following proper infection control practices.

2. Staff will be trained on infection control precautions during orientation. Training will include proper procedure for wearing aprons related to food service. Competencies will be assessed during orientation and periodically there after. A review of infection control protocol will be part of each staff meeting.

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

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

Based on observation, interview and record review, it was determined the facility failed to ensure resident to resident altercations were immediately reported to the local SPD office for 1 of 1 sampled resident (#3), and failed to immediately investigate injuries of unknown cause and unwitnessed falls, document the injuries and falls were not the result of abuse or neglect, and report the incidents to the local SPD office as suspected abuse for 2 of 2 sampled residents (#s 3 and 4). Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia.

Resident 3 was evaluated to have behaviors of being physically and verbally aggressive with staff during care.

Staff 3 (Universal Worker) reported Resident 3 had altercations with other residents.

Resident 3 was observed in an altercation with another resident on 3/29/22, slapping at each others hands. On 3/30/22, Resident 3 was observed to throw a brush at and strike Resident 4.

The following resident to resident altercations, incidents, and injuries of unknown origin, were documented in facility Observation Notes, Nursing Assessment form, and Accident/Incident/Occurrence Investigation forms:

*01/26/22 - "Right side of temple with small dots, says head and temple hurt on right side.";

*02/12/22 - "While assisting resident from bathroom to bedroom, I rolled the wheelchair wheel over [his/her] right pinky toe by accident. I did not look to make sure [his/her] feet were clear of the wheel before moving [him/her] forward..." The toe was fractured;

*02/16/22 - "...has been very easily agitated [s/he] has been trying to block #1 [Resident 4] from [his/her] hallway and keeps trying to follow #1 and starts to raise her hand...isn't wanting to leave #1 alone";

*02/19/22 -"Staff stated that room 1 [Resident 4] was pushing room 10 [Resident 3] in [his/her] wheelchair when room 10 did no want room 1 to push [him/her] anymore...Room 10 then became agitated and grabbed room 1 and pushed [him/her] into the wall."

*02/21/22 - "Observed a roughly 1 inch scratch on resident's left hand. Asked resident how [s/he] got it and all [s/he] said was "yeah"... it was bleeding so I cleaned it up and bandaged it..."

*2/24/22 -"...Has a sling to left arm, broken shoulder approx 2 weeks ago..."

*03/04/22 - "Resident trying to hit another resident...";

*03/08/22 - Returned from hospital following un-witnessed fall with pain to left hip.

*03/27/22 - Resident 3 was noted to have kicked another resident in the ankle multiple times.

For all altercations, staff noted they intervened and re-directed Resident 3.

The need to immediately report altercations, ensure injuries and incidents were investigated to rule out abuse or neglect, and reported to the local SPD office if abuse and neglect were not reasonably ruled out, was reviewed with Staff 1 (Administrator).

Staff 1 met with the local SPD staff in person on 3/31/22 to discuss and report the incidents above.

2. Resident 4 was admitted to the facility in 01/2022 with a diagnosis including dementia.

During the acuity interview on 03/29/22, Staff 3 identified bruising of unknown cause to resident 4's right chest.

Observation note dated 03/28/22 revealed a baseball size bruise that was purple and red and in the center was a nodule. There was no documented evidence the facility conducted an incident report to rule out abuse or neglect.

On 03/30/22, this surveyor asked Staff 3 (Universal Worker) to fill out an incident report and report the injury of unknown cause to SPD. The surveyor received the incident report and confirmation of the report sent to SPD at 4:33 PM on 03/30/22.

The need to investigate each resident incident and any injuries of unknown cause to rule out abuse and neglect was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

OAR 411-054-0028  Abuse Reporting and Investigation

1. Action taken on reporting accident and incident reports immediately after assessing and assisting resident. Staff is to report all incidents immediately to Administrator and RN regarding residents change of condition or any changes that are observed that are not consistent. Staff are required to immediately report abuse, suspected abuse to administrator or designee who will report to the local SPD office or local AAA office, this includes events overheard or witnessed by observation.

a.)Any infractions to be belived to be a crime, rape, murder, assult, burglary, controlled substances, theft or kidnapping are to contact law enforcement immediately. Physical injury of unknown cause must also be reported. Facility is to investigate all reports of abuse and suspected abuse and prevent the reoccurance, this includes time, date, place and individuals present.

b.)Description of reported event, staffs response at time of event, follow up action and administrators review. There is a no retailation policy in place for anyone involved. There are parameters in place for physician follow up communication for refusal of cares or change in health conditions that staff are trained to follow through with set up parameters to communicate resident changes to primary care physicians. Any reported falls or injury This violation correction will be put in place immediately and all needed updates for incident, accident, change of conditions will be promptly reported.

2.Correction will be a monthly audit to evaluate and ensure residents are getting individualized care and the most up to date care with any new change or condition

3.This correction will be evaluated each month to ensure violation will not be repeated,

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, and staff temp foods appropriately in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

The kitchen was toured on 03/29/22. The following areas were identified as needing cleaning or repair:

* Multiple cupboard doors were missing;

* Dried food on shelving in refrigerators;

* Sink full of dirty dishes;

* Dried food and liquids on counters;

* Undated opened foods in refrigerator;

* Uncovered food in refrigerator;

* Staff were not taking temperature of foods before serving the residents; and

* When directed to take food temperatures staff did not sanitize probe thermometer between food items.    

The need to ensure the kitchen was clean, in good repair, and staff monitored the temperature of food appropriately was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

240 OAR 411-054-0030 (1) (a)

1. A deep clean of the kitchen will be completed to include all drawers and cupboards, interior and exterior. The interior of cupboards and drawers will be lined with a washable surface. Pantry food will be properlylabeled and dated if opened and placed in appropiate containers.

2.Cleaning schedule check lists will be reviewed and updated to reflect daily, weekly and monthly cleaning and sanitizing. All staff will be provided training on updated cleaning and sanitizing schedules. The system has a binder log in place to track and view food teperatures, water temperatures and freezer temperatures. Maintenance staff have been hired to upkeep consistent maintenance on the entire buildings needs.

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

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

Based on observation, interview and record review, it was determined the facility failed to provide an activity program based on individual and group interests. Findings include, but are not limited to:

During the re-licensure survey, 03/29/22 through 03/31/22, there was a lack of unscheduled and scheduled activities that occurred for residents.

There was no posted activity calendar or scheduled activity program.

Staff were Universal Workers and responsible for caregiving, medications administration, housekeeping, laundry, and meal preparation and service in addition to providing activities.

No activities were observed to be provided:

*03/29/22  from approximately 3:00 pm to 5:30 pm;

*03/30/22 from approximately 7:30 am to 5:30 pm; and

*03/31/22 from 7:15 am to 10:30 am.

Interviews with residents and a visitor revealed the following regarding activities:

*"Not much...sit around";

*"Have not seen activities happen"; and

*"Bingo used to happen, not in awhile..."

During the survey, an un-sampled resident was observed to wander in the facility repeating "What do I do? Where do I go? There is nothing going on."

The lack of an activity program based on individual and group interests was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the lack of an activity program.

OAR 411-054-0030 (1)(c-d) Resident Services: Activities

1.Activities are currently and will be posted daily for residents as well as all scheduled activities.Programs will target individual and group activities.

2.The activities will be mandatory and completed as part of each residents care plan to ensure life enrichment and person centered care.

3.This correction will be monitored daily and monthly through daily and monthly audits.

4.The administrator will be responsible to see tht corrections are completed and monitored.

2. Resident 2 was admitted to the facility in 01/2017 with diagnoses including obesity and seizures.

A review of Resident 2's clinical record revealed a quarterly evaluation had been completed 12/30/21. Further review of the resident's record indicated Resident 2 had experienced a significant change of condition and decline. The evaluation was inaccurate and not reflective of the resident's current health status and care needs in the following areas:  

* Urinary catheter use;

* Need of full assistance with transfers, bathing, toileting, and personal hygiene by two staff; and

* Open wound to back of thigh.

The evaluation, completed 12/30/21, did not include updates related to the resident's significant changes in condition.

The need to ensure evaluations were reviewed and any updates documented each time a resident had a significant change in condition was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia.

A review of Resident 3's clinical record revealed a quarterly evaluation had been completed 12/14/21. Further review of the resident's record indicated Resident 3 had experienced a significant change of condition and decline. The evaluation was inaccurate and not reflective of the resident's current health status and care needs in the following areas:

* Decline in mobility from ambulating with walker to using wheelchair with personal alarm;

* Fracture to shoulder; and

* Fracture to toe.

The evaluation, completed 12/14/21, did not include updates related to the resident's changes in condition.

The need to ensure evaluations were reviewed and any updates documented each time a resident had a significant change in condition was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure new move in evaluation included all required elements  for 1 of 1 sampled resident (# 1) and evaluations were updated after significant changes for 2 of 2 sampled residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Review of Resident 1's initial move-in evaluation dated 12/28/21 revealed the following missing components:

* Visits to health practitioner, ER, hospital or NF in the past year;

* Vital signs if indicated by provider, health problems, or medications;

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

* Ability to use the call system;

* pharmaceutical and non-pharmaceutical interventions for pain and how the person expresses pain;

* List of treatments;

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

* Fall risk or history;

* Complex Medication regimen;

* History of dehydration or unexplained weight loss;

* Recent losses;

* Unsuccessful prior placements;

* Alcohol or drug use; and

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

The need to ensure all required elements on the new move in evaluation were addressed was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

OAR 411-054-0034 (2-4) Resident Move-in and Eval: Res Evaluation

1.Evaluation and pre admission assessments

Residents will have RN to complete any changes of conditions and assessments to include any transitions to hospice or home health. This includes a complete functional and full admission assessment from RN. A full resident functional evaluation for move in evaluation.

A completed move in evaluation will be preformed and filled for staff to have complete understanding of plan of care. Any future potential residents will have a complete evaluation filled prior to admission to best determine meeting all needs of care of resident.  The resident evaluation will address the following The resident evaluation must address the following

elements:

(a) Resident routines and preferences including:

(A) Customary routines, such as those related to sleeping,eating, and bathing;

(B) Interests, hobbies, and social and leisure activities;

(C) Spiritual and cultural preferences and traditions; and

(D) Additional elements as listed in 411-054-0027(2).

(b) Physical health status including:

(A) List of current diagnoses;

(B) List of medications and PRN use;

(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and

(D) Vital signs if indicated by diagnoses, health problems, or medications.

(c) Mental health issues including:

(A) Presence of depression, thought disorders, or behavioral or mood problems;

(B) History of treatment; and

(C) Effective non drug interventions.

(d) Cognition, including:

(A) Memory;

(B) Orientation;

(C) Confusion; and

(D) Decision-making abilities.

(e) Personality, including how the person copes with change or challenging situations.

(f) Communication and sensory abilities including:

(A) Hearing;

(B) Vision;

(C) Speech;

(D) Use of assistive devices; and

(E) Ability to understand and be understood.

(g) Activities of daily living including:

(A) Toileting, bowel, and bladder management;

(B) Dressing, grooming, bathing, and personal hygiene;

(C) Mobility ambulation, transfers, and assistive devices; and

(D) Eating, dental status, and assistive devices.

(h) Independent activities of daily living including:

(A) Ability to manage medications;

(B) Ability to use call system;

(C) Housework and laundry; and

(D) Transportation.

(i) Pain pharmaceutical and non-pharmaceutical

interventions, including how a person expresses pain or discomfort.

(j) Skin condition.

(k) Nutrition habits, fluid preferences, and weight if indicated.

(l) List of treatments type, frequency, and level of assistance needed.

(m) Indicators of nursing needs, including potential for

delegated nursing tasks.

(n) Review of risk indicators including:

(A) Fall risk or history;

(B) Emergency evacuation ability;

(C) Complex medication regimen;

(D) History of dehydration or unexplained weight loss or gain;

(E) Recent losses;

(F) Unsuccessful prior placements;

(G) Elopement risk or history;

(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and

(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.

(o) Environmental factors that impact the resident's behavior including, but not limited to:

(A) Noise.

(B) Lighting.

(C) Room temperature.

2.Residents will not be admitted until the evaluation has covered all previous subjects. This will be monitored by myself every admission with RN and follow up visits made to address any changes needed, I will be responsible to see that these corrections are made for all future residents.

Registered Monitoring Communication system for any resident identified to have a change of condition including but not limited to, return from hospital, signs or symptoms of urinary tract infection, new or missed medication etc. Staff will initiate the alert log , including resident name, change identified, start a temporary service plan, and complete proper notificatios to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to nurse/physician per the temporary service plan which corresponds with the residents change of condition. The temporary service planwill have specific directions for staff including what to look for, interventions put into place, signs and symptoms to report, who to report to and staff signature lines to sign once they have read and uderstood the temporary service plan. Staff will monitor the residents until the resident condition resolves and they are back to their baseline. Staff will receive in-serviceing specific to monitoring  for short term change of condition, appropiate documentation related to the change and when to notify the Nurse. The 24 hour binder will be set up to include but not limited to shift to shift communication log, alert charting log,

temporary service plan, significant change of condition log, and weekly skin monitoring log.

24 hour book/process will be reviewed daily during stand up/clinical meetings as a means to identify potential significant changes that need to be assessed by registered nurse. The system will be reviewed daily in a clinical review to ensure compliance is maintained. The administrator or designee and registered nurse will be responsible to ensure the corrections are completed/monitored.   

The nurse to complete a change of condition assessment including bed bound, heel protectors, feet floated on pillows and a review of overall health statuses. The service plan will be updated to ensure current needs and prefereces are met. Resident willl have on going nursing follow ups related to changes. Updates will be made as needed. Any staff are to update administrator and RN of any changes to be addressed. Every new resident will be evaluated with RN and signiture on assessment functional to indicate a complete evaluation has been performed to ensure the facility can meet all the needs of the resident.

3.Monthly audits will be preformed to ensure every new admitted resident has had complete evaluations.

4.The administrator/designee will be responsible for corrections to be completed and monitored

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

1. Resident 1 was admitted to the facility in 01/2022 with a diagnosis of dementia.

Observations of Resident 2 during survey, interviews with staff, review of the service plan, observation notes, and general records revealed the service plan was not reflective and did not provided clear direction to staff in the following areas:

* Catheter care;

* Behavioral plan;

* Ambulation status;

* Safety checks for mental health status;

* Elopement risk; and

* Use of insulin.

The need to ensure service plans were reflective of resident's needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2017 with diagnoses including obesity and chronic UTIs.

Staff interviews revealed Resident 2 required two staff for assistance with transfers, bathing, had a urinary catheter in place, and was receiving Home Health care for an open wound to the back of the left thigh.

Resident 2's bed was observed with a side rail on the left side of the bed. Resident 2 explained it was used for bed mobility.

Resident 2 had experienced a significant change of condition and decline. The service plan dated 12/30/21 was not updated to be reflective of the resident's current health status and care needs in the following areas:  

* The need for two staff for assistance with transfers, hygiene, and bathing;

* Wound care;

* Clear instructions and precautions for the use of side rails; and

* Clear instructions for catheter care.

The need for clear instruction for staff, accuracy of service plans, and updating of service plans following significant changes was reviewed with Staff 1 (Administrator) on 3/30/22. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia with behaviors.

Staff interviews revealed Resident 3 had behaviors including altercations with other residents, was no longer ambulating with a walker, and used a personal alarm at all times.

Review of Resident 3's clinical record indicated a history of a fractures to both the left shoulder and the right little toe.

Resident 3 had experienced a significant change of condition and decline. The service plan dated 12/30/21 was not updated to be reflective of the resident's current health status and care needs in the following areas:

* Mobility status and devices;

* Fractures;

* The use of a personal alarm and instruction to staff; and

* Behaviors including altercations with other residents and interventions.

The need for clear instruction for staff, accuracy of service plans, and updating of service plans following significant changes was reviewed with Staff 1 (Administrator) on 3/30/22. She acknowledged the findings.

C 260 OAR 411-054-0036 (1-4) Service Plan:

General Service Plan:

1.Resident's service plan will be updated to provide accurate clear information in the following area's; Fall injury reduction interventions including the use of a mat at bedside, egg crate mattress and services provided by hospice.

2.Resident's service plan will be updated to provide clear accurate  information for interventions related to the diagnosis of insulin dependent diabetic, including signs/symptoms of hypo/hyperglycemia and who/when to notify.

All resident service plans will be audited to ensure the who, what, when, how and why instructions

for each area of need identified via the evaluation has clear direction to staff on the delivery of service.

3.Service plans will be audited on a minimum of quarterly during the regularly scheduled quarterly service plan process or with a signifcant

change of condition.

4.The Administrator and/or designee and Licensed

Nurse will be responsible to ensure the system has been completed/monitored.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions developed, and the condition was monitored for 3 of 3 sampled residents who experienced short term changes of condition. The facility failed to evaluate residents with significant changes in condition, refer to the facility nurse, document the change, and update the service plan as needed for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes in condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2017 with diagnoses including obesity and chronic UTIs.

The resident's 12/30/21 service plan, 01/01/22 through 03/30/22 Observation Notes, PRN Care Reports, temporary service plans, and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and lacked resident specific directions to staff in the following areas:

* UTI;

* Medication change;

* Rash; and

* Fall.

Resident 2 experienced the following significant changes without documented evidence of an evaluation, referral to the facility nurse, and update of the service plan:

*Open wound to the back of the thigh; and

*New catheter.

The need to ensure changes of condition were evaluated, referred to the RN if significant, had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 06/2017 with diagnoses including dementia.  

The resident's 12/31/21 service plan, 01/01/22 through 03/30/22 Observation Notes, PRN Care Reports, Nursing Assessment form, and physician faxes were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and lacked resident specific directions to staff in the following areas:

* Skin conditions including injuries and rash;

* Verbal and physical altercations with other residents;

* Episode of "head spinning, dizzy";

* UTI;

* Medication changes; and

* Fall with pain.

Resident 3 experienced the following significant changes without documented evidence of an evaluation, referral to the facility nurse, and update of the service plan:

* Fracture of the toe;

* Fracture of the shoulder; and

* Change in ambulation from using walker independently to using wheelchair with alarm.

The need to ensure changes of condition were evaluated, referred to the RN if significant, had documentation to reflect monitoring to resolution at least weekly and provided clear resident specific directions to staff was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

3. Resident 1 was admitted to the facility in 01/2022 with a diagnosis of vascular dementia.

Review of resident 1's observation notes and general record revealed there was no evidence the following changes were monitored until resolved:

* Suicidal thoughts and expressing s/he wanted to die;

* Multiple ER visits;

* Behaviors including smearing feces on her face; and

* New order to have medications crushed.

The need to ensure the facility monitored short term changes of condition at least weekly until resolution was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

OAR 411-054-0040 Change of condition and Monitoring

1.Registered nurse to complete a change of condition assessment to include transition to hospice, tooth loss, food texture change and review of all overall health status.

The service plan will be updated to ensure current needs and preferences are met.

2.Resident will have on-going nursing follow up related to the change, updates will be made as needed.

Nursing will complete a comprehensive assessment of current health status to include previous hospitilazations and health changes. The service plan will be updated to ensure current needs and preferences are met. Resident will have on-going nursing follow up related to any changes identified, updates will be made as needed.

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

The community will implement a 24 hour

communication system.

The "24 hour binder" will be set up to include but not limited to:

a) Shift to Shift Communication Log

b) Alert charting log

c)Temporary Service Plan

d) Signifcant Change of Condition Log

e) Weekly Skin Monitoring Log

Staff will start Short Term Monitoring / Communication System for any resident identified to have a change of condition including but not limited to, return from hospital, signs or symptoms of urinary tract infection, new or missed medication etc.. Staff will initiate the alert log, including resident name, change identified, start a temporary service plan, and complete proper notifications to ensure they monitor resident and identify when to report concerns to nursing or physician. The staff will be aware of what to report to nurse and/or physician per the temporary service plan  which corresponds with the resident change of condition. The Temporary Service Plan will have specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report, who to report to and staff signature lines to sign once they have read and understood the Temporary Service Plan.

Staff will monitor the residents status until the resident condition resolves and they are back to their baseline.

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

3.The system will be reviewed daily in clinical review to ensure compliance is maintained.

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

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 2 and 3) who experienced significant changes in condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 1/2017 with diagnoses including obesity and chronic UTIs.

During the acuity interview, Resident 2 was identified to receive home health services for wound care and a new catheter.

There was no documented evidence of an RN assessment of Resident 2's open wound or the new catheter. There was no update to the service plan providing instructions to staff for Resident 2's significant changes.

On 03/30/22, the need to ensure the facility RN completed an assessment for significant changes of condition, including developing a plan of care to address the wound and provide catheter care, was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 3 was admitted to the facility 06/2021 with diagnoses including dementia.

Review of Resident 3's clinical record indicated s/he had experienced fractures of the right little toe and the left shoulder.

There was no documented evidence of an RN assessment of Resident 3's fractures. There was no update to the service plan providing interventions and instructions to staff for Resident 3's significant changes.

On 03/30/22, the need to ensure the facility RN completed an assessment for the significant changes of condition, including developing a plan of care to address the fractures, was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0045 Resident Health Services

1.Residents who will have a signifcant change of condition assessment specific to new diagnosis of Insulin Dependent Diabetic. Service plan will be updated with clear instructions and interventions to minimize risk of complications. Resident will have on-going nursing follow up related to this change until a new baseline can be established or resident returns to historical baseline.

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

The Resident will be entered into the 24-hour report document.  If warrranted the resident will be placed on the alert log with all supporting components being completed, including Provider notifications as needed.

The Registered Nurse will utilize the significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status or a new baseline is established. The Registered Nurse will update the Service Plan based on the nursing assessment to ensure staff are notified of the Residents current needs and preferences. The Registered Nurse will coordinate care with the Residents Provider related to any on-going changes or care needs based off of weekly assessments.

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

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

Based on interview and record review, it was determined the facility failed to ensure written recommendations made by outside service providers were incorporated in resident's service plans as applicable, and the instructions were made available to staff for provision of supplemental care for 1 of 1 sampled resident (# 2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 06/2017 with diagnoses including obesity.

Review of Resident 2's clinical record noted s/he had been receiving Home Health wound care. Home Health visit notes indicated the outside provider left the following recommendations for care:

* 01/11/22: "Apply Calazine to [bilateral] thighs and peri-area"

* 02/28/22: "keep skin wound [clean, dry, and intact] dressing in place and replace PRN. Keep wounds on [left] leg covered with silicone dressing or optifoam for padding." and

* 3/28/21: "Please keep [left] thigh wound covered with padded dressing change PRN. Check dressing daily."

There was no documented evidence the facility had communicated the recommendations to staff.

On 03/30/22 the need to ensure recommendations from outside service providers were reviewed and interventions added to the service plan and communicated to staff as appropriate for provision of care was discussed with Staff 1 (Administrator). She acknowledged the findings.

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

1.The facility will ensure written recommendations made by outside service providers are incorporated in resident's service plans as applicable, and the instructions were made available to staff for provision of supplemental care. Placement of post visit notes will be available in a binder located next to the office door for staff to review notes and changes to impliment. If post visit notes are not left, staff are instructed to contact third party agency and request a faxed copy of notes.

Following a resident's visit to an outside medical provider, if information is obtained from said provider, it must be included in the resident's record. Adjustments to the resident's services and service plan must be made as applicable.

The facility will provide relevant information to the off-site provider and must have a protocol to facilitate the receipt of information from the provider.

The facility management or licensed nurse must be notified of the services provided by the outside provider to ensure that staff are informed of new interventions, and that the service plan is adjusted if necessary, and reporting protocols for communiication are in place.

The facility nurse will review the resident's health related service plan changes made as a result of the provision of on-site health services noted.

The facility staff will follow policies to ensure that outside service providers leave written information in the facility that addresses the on-site services being provided to the resident and any clinical information necessary for facility staff to provide supplemental care.

2. The facility administrator and staff need to ensure recommendations from outside service providers are reviewed and interventions added to the service plan and communicated to staff and RN as appropriate for provision of care.

The updated service plan must be readily available to staff and provide clear direction regarding the delivery of services.This includes third party agencies including home health and hospice

The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided by third party agencies.

3. This correction will be reviewed daily and monthly as needed per third party visit to ensure any changes or cares can be immediately implimented.

4. Administrator or designee and Registered Nurse will be responsible to ensure the system has been corrected/monitored.

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 (including a Memory Care Community) 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 where staff failed to wear their face mask properly, exposing their nose and mouth, wearing cloth masks, and not wearing N95 mask when providing ADL assistance to a resident who tested positive for COVID-19.

The need to ensure staff consistently wore face masks appropriately was reviewed with Staff 1 (Administrator) and Staff 8 (Administrator Designee) on 09/20/22. Staff acknowledged the findings.

C 295 OAR 411-054-0050 (1-5) Infection Prevention & Control

1. Staff will be provided training on infection control practices including proper masks to be worn daily, and during a Covid-19 outbreak. Training will include proper placement of masks as well as Covid 19 guidelines.

2. Training will include proper masks, placement of masks and Covid 19 guidelines. Competencies will be assessed during orientation; staff will be observed daily to ensure staff are following proper infection control practices. A review of infection control protocol will be part of each staff meeting.

3. This area will be evaluated during orientation period, daily and at monthly staff meetings.

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

2. Resident 3 was admitted to the facility in 06/2017 with diagnoses including dementia, atrial fibrillation and insomnia.

Review of Resident 3's current physician orders and 03/01/22 through 03/29/22 MARs revealed there were no signed physician orders for:

* Apixaban 2.5 mg twice daily for blood thinner; and

* Melatonin 3 mg once daily before bed for sleep.

The need for signed orders to be in place for all medications the facility was administering was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings and received orders for the medications.

Based on interview and record review, it was determined the facility failed to ensure signed physicians' orders were documented in the residents' facility record for all medications and treatments the facility was responsible to administer, for 2 of 3 sampled residents (#s 1 and 3) whose MARs and orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 01/2022 with a diagnosis of vascular dementia.

Resident 1's most recent signed physician's orders and 03/01/22 through 03/29/22 MAR was reviewed, and the following deficiencies were identified:

There were no written, signed orders for the following medications in Resident 1's record:

* Amlodipine Besylate oral Tablet 5 mg for blood pressure;

* Potassium chloride ER Oral Tab 10 MEQ for supplement;

* Sertraline HCL oral tab 50 mg for for depression;

* Ondansetron HCL tab 4 mg for nausea; and

* Oxycodone HCL oral tab 5 mg pain.

The need to ensure signed physician's orders were documented in the resident's facility record for all medication and treatments the facility was responsible to administer was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings and received orders for the medications.

303 OAR 411-054-0055 Systems: Treatment Orders

1. Residents medication and treatment records will be reconciled to ensure all medications and treatments have current signed providers orders, are accurate and dispensed as prescribed to the resident.

2.All resident medication and treament orders will be reconciled to ensure medications and treatments are dispensed as ordered.

3.Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimun of two staff. Further, daily audits to review missing medications, omissions and PRN usage will be completed with non drug interventions included.

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

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided clear instruction and parameters for administration of PRN medications for 2 of 3 sampled residents (#s 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2017 with diagnoses including obesity.

Resident 2's 03/01/2022 through 3/29/22 MARs were reviewed.

Resident 2 had orders for:

* Potassium CL ER 20 meq once daily; and

* Weekly weights on Tuesdays.

The documentation on the MAR for the medication administration and weight monitoring was conflicting:

* The Potassium was noted to not be available or "unable to find medication" on alternating days it was documented as administered; and

*The scale was noted to be broken so weights not taken and weights were documented as taken on the same days.

The conflicting documentation was reviewed with Staff 1 (Administrator) on 03/30/22. She acknowledged the MAR was not accurate.

2. Resident 3 was admitted to the facility in 06/2021 with diagnoses including dementia.

Resident 3's 03/01/2022 through 3/29/22 MAR was reviewed.

Resident 3 had two PRN medications for pain.

There were no resident specific parameters to direct non-licensed staff in the administration of the as needed pain medications.

The need to ensure MARs included clear directions for as needed medications to direct non-licensed staff which medication to administer was reviewed with Staff 1 (Administrator). She acknowledged the findings.

310 OAR 411-054-0052 Medication Administration, 1.Medication and treatment records will be updated to include accuracy and reason for use. PRN medications/treatments will be updated to ensure clear resident specific parameters, reason for use and order of administration.

2.All resident medications and treatments records will be audited to ensure accuracy and reason for use.

Additionally, all PRN medications and treatments will be audited to ensure clear resident specific parameters, reason for use, order of administration with clear directions/instructions for staff to follow.

3.The system will be reviewed with all new resident prescribed orders. Training with medication techs on who to alert when new precribed medications / treatments lack reason for use and PRN medications / treatments that require, order of administration or resident specific parameters. Additionally, a quarterly medication reconillation will be completed for each resident to ensure reason for use and PRN medications / treatments have clear resident specific parameters, reason for use, order of administration and clear directions/instructions for staff to follow.

4.The Administrator and/ or designee and  Licensed

Nurse will be responsible to ensure the system is corrected/monitored.

Based on interview and record review, it was determined the facility failed to employ a qualified full-time Administrator. Findings include, but are not limited to:

The survey team entered the facility at approximately 3:00 pm on 03/29/22. Staff 3 (Universal Worker) revealed the Administrator was not currently in the building.

In an interview with Staff 3 on 03/29/22 at approximately 4:15 pm, when asked how often the administrator comes into the facility, she indicated Staff 1 (Administrator) had not been in the facility for a few weeks and came into the building about one day a month.

In an interview with Staff 4 (Universal Worker) on 03/30/22 at approximately 9:25 am, she confirmed Staff 1 comes into the building about once a month but had not seen her in a couple months.

In an interview by phone with Staff 1 (Administrator) on 03/29/22 at approximately 5:00 pm, she said she was not in the facility 40 hours a week and usually came into the building once a week. During the winter months, Staff 1 indicated she did not make it into the facility very often.

The need to ensure the facility employed a qualified full-time Administrator was discussed with Staff 1. She acknowledged the findings.

OAR 411-054-0065 (1) Administrator Qualification and Requirements .

1. Licensed administrator will be present the required 40hours a week alternating every other week with a second licensed administrator. Staff is currently positioning to attend 40 hour administrator licensing course to test for licensing.

2.A licensed administrator will be hired specifically for Burns Shasta building.

3.This will need to be evaulated to correct daily until an  administrator is properly trained and in place.

4. The administrator will be responsible for seeing that the 40 hour commitment is honored.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. The facility failed to have enough staff to meet the health and safety needs of the residents. Findings include, but are not limited to:

On 03/29/22 at approximately 3:15 pm, Staff 3 (Universal Worker) reported the facility was home to 10 residents, two of which required the assistance of two staff with transfers and ADL care. Staff 3 explained there were multiple residents with behaviors requiring re-direction and intervention.

Staff 3 was the only staff working in the facility.

The facility utilized Universal Workers who were responsible for caregiving, medication administration, housekeeping, laundry, activities, and meal preparation and service.

There was only one staff member on duty from 11:00 pm to 5:00 am and 11 am to 5:00 pm every day.

Staff 3 was directed to immediately ensure there were at least two staff scheduled at all times. Additional staff arrived at the facility by 5:00 pm and it was confirmed two staff were scheduled for the overnight shift.  Two staff were noted to be on shift for all other days of the survey.

The facility had residents requiring two person assistance with ADLs and transferring. The facility routinely scheduled only one staff to care for ten residents. In addition to providing care, staff were universal workers and responsible for preparing and serving meals, passing medications, cleaning, laundry, and activities.  

Review of records and interviews with staff revealed showers were documented as not provided due to the lack of two staff to provide assistance. Multiple resident to resident physical altercations were observed during the survey.

On 03/30/22 Staff 1 (Administrator) acknowledged there were not enough staff to meet the scheduled and unscheduled needs of the residents.

Refer to C 242

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing

1.The licensed adminitrator has developed a schedule for all staff to accommodate the needs of the community at 24 hours a day. The facility is currently hiring and utilizing outside staffing agencies to qualify and be properly trained in a timely fashion. Staff were scheduled to work rotating 12 hour shifts to have two eople on floor at all times. Administrator Teresa Kuder and Nathaniel Figueroa are scheduled to tend the facility every other week to compensate for all things compliant and required 40 hours per week.

2.The system will be corrected by grooming staff who qualifies under the Administrator Reference summary to attend a 40 hour training course for preliminary administrator certification and to progress to the administrator licensing exam. The facility is accomodating for residents who require two person assistance with ADLs and transfers. The facility will continue to prospect for qualified staff for the Burns Oregon Demographic.

3.The correction is being evaluated daily until sufficient number of staff is reached and proper training.

4.Teresa Kuder and Nathaniel Figueroa will be responsible to see all corrections are completed and corrected.

Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing. Findings include, but are not limited to:

During a review of staff training records on 03/30/22, Staff 1 (Administrator) was unable to provide documented evidence the sampled newly hired staff had demonstrated competency in all duties they were assigned or completed all pre-service training. Staff 1 further confirmed the lack of administrative oversight led to the staff not completing pre-service training and demonstration of competency in all required areas within 30 days of hire.

The need to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 on 03/30/22. She acknowledged the findings.

Refer to C 370 and C 372

OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts.

1.Ashley Manor will ensure t has a training program that included methods to determine competency of direct care staff through evaluation, observation, and written testing.Staff are required to complete the pre-service training and demonstration of competency in all required areas within 30 days of hire. The facility will provide a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing.

2.The facilities program includes methods to determine competency of direct care staff through evaluation, observation, or written testing. Facility shall also maintain documentation regarding each direct care staff ' s demonstrated competency.

3. This correction will be evaluated daily upon an employees 30-60-90 days of hire. A signed checklist of proven compitencies will be provided and signed off by witness of said compitencies.

4.The Administrator and/ or designee and Licensed

Nurse will be responsible to ensure delegation and that the system is corrected/monitored.

Based on interview and record review, it was determined the facility failed to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing. This is a repeat citation. Findings include, but are not limited to:

During a review of staff training records on 09/20/22, Staff 1 (Administrator) was unable to provide documented evidence one sampled newly hired staff had demonstrated competency in all duties they were assigned or completed all pre-service training.

The need to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 on 09/20/22. She acknowledged the findings.

Refer to C370 and C372.

C 365 OAR 411-054-0070 (2) Staffing Rqmt and Training: Training Rqmts

1.Staff (#9) has completed the required pre-service orientation including Residents rights and values of community-based care; Abuse reporting requirements; infectious disease prevention; and Fire safety and emergency procedures as well as pre-service dementia care training with printed certification.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, the administrator Designee will be provided training on the Training program including mandatory pre-service requirements before providing direct care to residents. The Employee Training grid/audit has been updated to reflect all required components.

3. Staff training records will be evaluated each time before a newly hired staff member is allowed to provide direct care to residents. The Employee training grid/audit has been updated in the Quality Assurance Administrator audit, this audit is completed monthly.

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

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly hired Universal Workers (#s 3, 5 and 7). Findings include, but are not limited to:

Review of the facility's training records on 03/30/22 indicated the following:

Staff 5 (Universal Worker) hired 03/09/22 and Staff 7 (Universal Worker) hired 12/08/21 lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.

Staff 3 (Universal Worker) hired 01/25/22, Staff 5 and Staff 7 lacked documented evidence of completing the following pre-service orientation:

* Resident rights and values of community-based care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

The training program and requirements were discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

OAR 411-054-0070 Staffing Rqmts and Training: Caregiver Rqmts

1.Staff will complete preservice dementia training and preservice orientation.

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

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

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

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed, with certification, prior to staff providing direct care to residents for 1 of 2 newly hired Universal Worker (#9). This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 09/20/22 indicated the following:

Staff 9 (Universal Worker) hired 08/17/22 lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents, and the following required pre-service orientation:

* Resident rights and values of community-based care;

* Abuse reporting requirements;

* Infectious disease prevention; and

* Fire safety and emergency procedures.

The training program and requirements were discussed with Staff 1 (Administrator) and Staff 8 (Administrator Designee) on 09/20/22. They acknowledged the findings.

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

1. Staff #9 has completed the required pre-service orientation including Residents rights and values of community-based care; Abuse reporting requirements; Infectious disease prevention; and Fire safety and emergency procedures as well as preservice dementia training with certification.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, the administrator Designee will be provided training on the orientation requirements: Including pre-service orientation and pre-dementia training with certification. The Employee Training grid/audit has been updated to reflect all required components.

3. Staff training records will be evaluated each time before a newly hired staff member is allowed to provide direct care to residents. The Employee training grid/audit has been updated in the Quality Assurance Administrator audit; this audit is completed monthly.

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 3, 5 and 7) had demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 03/30/22 indicated the following:

1. Staff 3 (Universal Worker) hired 01/25/22, Staff 5 (Universal Worker) hired 03/09/22 and Staff 7 (Universal Worker) hired 12/08/21, had not demonstrated competency within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal Aging;

* Identification, documentation and reporting changes of condition; and

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

2. Staff 7 lacked documented evidence of demonstration of competence for Medication Administration.

The Surveyor notified Staff 1 (Administrator) Staff 7 could not administer medications until she had documented evidence of demonstrating competency. Staff 1 removed Staff 7 from medication administration duties and notified Staff 2 (Universal Worker/House Manager) she could not administer medications until competence had been demonstrated.

The need to ensure staff had documented evidence of competency demonstration in all assigned duties, within 30 days of their hire date, was discussed with Staff 1. She acknowledged the findings.

OAR 411-054-0070 Training care staff within 30 days

1.An audit will be completed and any staff without the the required demonstrated competencies within 30days of hire including Role of service plas in providing individualized care, providing assistance with ADL's changes associated with normal againg, identification and documentation and reporting changes of condition, conditions that require assessment,  treatment and observations and reporting will be provided in training, An audit of staff training records will be completed and any staff without required First Aid training and abdominal thrust training will be provided the training.

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

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

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

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly hired staff (#9) had demonstrated competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 09/20/22 indicated the following:

Staff 9 (Universal Worker), hired 08/17/22, had not demonstrated competency within 30 days of hire in the following required areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition; and

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

The need to ensure staff had documented evidence of competency demonstration in all assigned duties, within 30 days of their hire date, was discussed with Staff 1 (Administrator) and Staff 8 (Administrator Designee). They acknowledged the findings.

C 372 OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1. Staff #9 has completed demonstration of competencies for 30 day orientation including, Role of service plans in providing individualized care; Providing assistance with ADLs; Changes associated with normal aging; Identification, documentation and reporting changes of condition; and Conditions that require assessment, treatment, observation and reporting.

2. To ensure the system is corrected and staff remain in compliance with all training requirements, the administrator Designee will be provided training on the requirements for documentation regarding the demonstration of competencies for 30 day orientation. The Employee Training grid/audit has been updated to reflect all required components.

3. Staff training records will be evaluated each time before a newly hired staff member is allowed to provide direct care to residents. The Employee training grid/audit has been updated in the Quality Assurance Administrator audit, this audit is completed monthly.

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

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

On 03/30/22, fire drill and fire and life safety training records for the previous six months were requested.

Staff 1 (Administrator) reported fire drills and fire life safety training had not been done. She acknowledged the fire drills and fire and life safety instruction requirement was not met.

OAR 411-054-0090 Fire safety and life safety drills and instruction.

1.To correct the rule violation, an unannounced fire drill will be conducted with each shift to ensure all staff are trained on appropiate and safe response to a fire alarm.

2.The system will be corrected so this violation will not happen again by unannounced drills and recording them at a minimum of every other month at different times of the day, evening, and night shifts.

Fire safety instruction to staff will be provided on alternate months. The fire drill document will include the following components:Date, time, and day

Location of simulated fire or origin,The escape route used, Problems encountered and comments relating to residents who resisted or failed to participate in the drills, Evacuation time period needed, Staff members on duty and participating, Number of occupants evacuated.

3.The fire drill components and fire and life safety instruction documents will be reviewed on a monthly audit basis.

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

Based on interview and record review, it was determined the facility failed to instruct residents at least annually 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, failed to ensure a written record of fire safety training, including content of the training sessions and the residents attending, was kept, and failed to document alternating exit routes during fire drills. Findings include, but are not limited to:

On 03/30/22, Staff 1 (Administrator) reported there was no evidence of annual training of residents fire procedures and no evidence of fire drills including evidence of alternating exit routes.

Staff 1 acknowledged the requirements of fire drill evacuation training and practice were not met.

OAR 411-054-0090 Fire and Life Safety: General

1. All residents will be instructed on 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, and re-instructed annually.

2 New residents will be instructed within 24 hours of move in and re-instructed annualy for 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.

3 A written record of the fire safety training including content of the training sessions and the residents attending/trained will be retained.

4 The administrator and/or designee will review monthly to ensure corrections are made and all residents are up to date on this training.

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

Refer to C160, C295, C365, C370 and C372.

C 455 OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

Refer to C160, C295, C365, C370 and C372

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

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

* Cigarette butts littered the back patio, yard, planter boxes, and vent wells next to the house;

* A wheelchair stacked with papers, books, plastic bottle, and cigarette butts was left on the patio;

* Drop-offs from the sidewalk to the adjacent planting beds of approximately six inches;

* Dried Christmas tree leaning against the side of the facility;

* Plastic Christmas garland lying in the yard;

* Broken siding on the corner of facility by the gate;

* Debris and litter in the yard;

* Yard maintenance equipment lying about the yard including, but not limited to: shovel, extension cord, hose, ladder, and lawn mower;

* Dead potted plants stacked in corner of patio area;

* Large table umbrella folded and lying on patio;

* Accumulation of dried leaves and tumbleweeds; and

* Overgrown thorn bush blocking the sidewalk in the lower yard.

The building exterior was reviewed with Staff 1 (Administrator) on 03/30/22.  She acknowledged the findings.

411-054-0200 (3) General Building Exterior

1. Immediate actions to correct the rule violation include filling in the drop-offs at pathway edges in excess of three inches in multiple areas and repair of cement pathway near the smoking section in back courtyard.

The staff and maintenance will ensure exterior grounds were orderly, free of litter and refuse, pathways were maintained in good repair, and storage will be provided for all maintenance equipment. Cigarette butts littered the back patio will be picked up, yard will be orderly, planter boxes orginized, and vent wells next to the house will be cleaned out by maintenence; adaptive equipment (wheelchair stacked with papers, books, plastic bottle, and cigarette butts) was left on the patio and will be remived and stored properly in place; concrete drop-offs from the sidewalk to the adjacent planting beds of approximately six inches will be adjusted with landscaping filler to make even; Dried Christmas tree leaning against the side of the facility will be properly disposed.

2. The system will be corrected so this violation will not happen again by completing consistent environmental walk throughs to ensure all exterior pathways and an outside areas are in good repair and any concerns are identified and followed up in a timely manor.

3.The area needing correction will be evaluated on a monthly basis with environmental audit. This includes visual  inspection "walk around" to address any new damage or ongoing maintenance.  

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

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair, and the electronic code, needed to use the exit door, was clearly posted for residents, visitors, and staff use. Findings include, but are not limited to:

Observations of the facility on 03/29/22 through 03/31/22 revealed the following:

* On 03/29/22, the code to exit the main entrance of the facility was hidden in a framed flower pattern. There was no code posed on 03/30/22 or 03/31/22;

* Multiple walls, doors, and door frames in the facility had scrapes, gouges, and chips;

* The common area bathrooms had a brown substance on the toilet seats and bowls, damage to the walls of the walk in showers, stained and soiled caulking around the shower entrances, an exposed metal bracket by the hand washing sink, and a tall garbage can filled with incontinent products and garbage;

* Multiple handrails had scrapes, gouges, and chips;

* The carpet in the common areas was stained and ripped in multiple places;

* Debris on the dining room floor, under the tables and chairs;

* The upper components of the fire place were missing exposing the interior mechanism;

* Room 2's bathroom door jamb had scrapes and gouges, the flooring was missing under the bathroom sink, and a soiled urinal was lying on the floor; and

* Room 10's bathroom door jamb had scrapes and gouges, soiled laundry was lying on the floor, and two screws were protruding from the wall by the bathroom mirror.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Administrator) on 03/30/22. The requirement to clearly post the electronic code, needed to use the exit door, was reviewed. Staff 1 acknowledged the findings explained repairs would be arranged.

OAR 411-054-0200 (4) Doors, Walls, Elevators, Odors.

1. Staff and maintenance will ensure the environment was maintained clean and in good repair, and the electronic code needed to use the exit door and main entrance is posted clearly posted for residents, visitors, and staff use. Scrapes, gouges and chips will all be repaired by newly hired maintanence manager. Wall damage to showers stained and soiled caulking on shower entrances as well as exposed metal brackets will be repaired and replaced. Tall garbage cans will be provided for incontinence products as well as soiled clothing/linen for laundry areas.

2. A walk through of the community will be completed every pre shift  to ensure all doors, walls, building equipment ie sinks, toilets, dispensers are properly working. Any house items used by residents that have a Lever-type door handle will be inspected for proper function. Carpet, missing flooring, fireplace, residents doorjambs will be replaced  or repaired by maintenance manager.

3. This area will be evaluated monthly as part of QA process and monthly audit due by the 5th each month.

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

Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing and also provided a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

A tour of the facilities laundry room on 03/30/22 revealed the following:

*A lower cupboard labeled "Dirty Laundry Only" had a metal frame in the interior that was filled with decorative pillows;

*Multiple piles of soiled laundry, including bedding, were noted on the floor, in open baskets and directly on the floor;

*Piles of linens and clothing, both visibly soiled and possibly clean, noted on the counters; and

*An approximately six inch hole in the flooring in front of the washing machine.

In an interview on 03/30/22, Staff 3 (Universal Worker) was unaware of any system to process soiled linen and laundry including a separate area with closed containers.

The need to ensure a separate area with closed containers was available which allowed for the storage and handling of soiled linens and clothing, and to ensure flooring without voids that can harbor insects or moisture, was discussed with Staff 1 (Administrator) on 03/30/22. She acknowledged the findings.

OAR 411-054-0200  Housekeeping and Laundry (7)(b-d)

1.Staff will ensure a separate area for laudry with closed containers available to allow storage and handling of soiled linens and clothing and also to provide a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Separate area with closed containers will be provided to avoid harboring insects or moisture to soiled linens.Floor will be repaired by maintenance manager.

2.Daily laundry shift duties will include monitoring appearance and function of laundry room and reporting any need for repair, restocking or clean up of room.

3. Daily auditing as well as monthly audits of laundry room functions will be evaluated.

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

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

A tour of the facility on 03/30/22, revealed the following:

*The common bathrooms water was turned on and noted to be hot to the touch. The water temperature, taken by the surveyor, was 122.3 degrees Fahrenheit;

*Room 2 resident's bathroom sink hot water was 122.2 degrees Fahrenheit;

*Room 10 resident's bathroom sink hot water was 122.1 degrees Fahrenheit.

On 03/30/22, the hot water temperatures were discussed with Staff 1 (Administrator), she verified the water was too hot. Staff 1 stated she would contact a maintenance staff from another facility to address the elevated water temperature.

OAR 411-054-0200 (9) Plumbing Systems

1.Building water temperature has been adjusted to meet the range of 110-120 degrees Farenheit.

2.The facility will monitor and obtain nightly water temps from every resident room to ensure no resident or staff is in danger of injury. The staff have been provided withh a local cooling and heating service asa back up in case equipment requires professional services.

3. Water temperatures are to be taken nighty and with a daily and monthly audit to detirmine any future action to maintain correct temps.

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

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building and that all residents had access to call system. Findings include, but are not limited to:

1. Observations on 03/30/22 revealed exit doors did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

2. The residents in rooms 1 and 10 did not have access to the facility call system.

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited and the need for access to a call system was discussed with Staff 1 (Administrator). She acknowledged the findings.

OAR 411-054-0200 (11-13) Call Sys, Exit Dr Alarm, Phones, TV, or Cable

1. Exit doors will be equipped with an alarming device to provide security and to alert the staff when residents exit the building. New call light system has been ordered and will be installed by maintenance manager.

2.Exit door alarms checks will be added to staff and administrator daily walk through task sheet to ensure proper functioning of alarms. Staff will receive inservicing on urgent and non-urgent repairs via facility maintenance log or Administrator.

3. The system will be evaluated daily.

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