The findings of the re-licensure survey, conducted 07/08/24 through 07/11/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
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 revisit to the re-licensure survey of 07/11/24, conducted 09/23/24 through 09/25/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the second revisit to the re-licensure survey of 07/11/24, conducted 12/30/24 through 12/31/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
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 third revisit to the relicensure survey of 07/11/24, conducted 03/11/25, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 1 of 2 sampled residents and two unsampled residents who received meal assistance and ADL care, and to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#8) who received care at bedside. Findings include, but are not limited to:
1. Meal service observations were made during the survey on 09/24/24.
On 09/24/24 at 12:12 pm, meal observations were conducted in the facility's activities room, which served as a secondary dining area. Resident 8 and three unsampled residents were receiving meal assistance from Staff 8 (CG) and Staff 9 (CG).
During the meal service, and while providing direct care to the residents, Staff 8 and Staff 9 continuously spoke to each other in a language other than which the residents could understand.
The need to ensure residents' right to be treated with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator) on 09/25/24. They acknowledge the findings.
2. Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia.
The current service plan, dated 09/23/24 identified the resident had the following care needs:
* Two-person assist for transfers using a hoyer lift; and
* Full assist with toileting and perineal care.
Observations of Resident 8's room revealed s/he shared a room with another resident. Staff 8 (CG), Staff 10 (CG) and Staff 22 (CG) were observed providing incontinence care and transfer assistance from bed to wheelchair for Resident 8 while his/her roommate was in the room. There was no observable barrier between the two sides of the room that provided privacy and dignity during ADL cares.
In addition, Staff 8, Staff 9 and Staff 22 continuously spoke to each other in a language that the resident could not understand.
An interview at 12:00 pm on 09/25/24 Staff 3 (Lead MT) acknowledged that the staff were supposed to escort the resident outside of the room or use a privacy screen when assisting Resident 8.
The need to ensure residents' right to be treated with dignity and respect, and receive services in a manner to protect privacy was discussed with Staff 1 (ED), Staff 2 (LPN, Residential Services Coordinator) and Staff 3 on 09/25/24. They acknowledged the findings.
1. Immediate staff training was completed with staff 8, 9 and 22 regarding Resident Rights and language barriers. Staff were reminded to speak in a language the resident's understand and the right to have privacy when being toileted or personal care is being performed.
2. All staff received retraining on Resident's Rights. Staff were directed to be speaking English around residents and not speaking to each other in Spanish to ensure the residents' rights are being met.
All staff received retraining on the Right to Privacy. Partitions have been ordered for every room and will be kept in the closet for use unless the resident prefers to have them at all times.
3. This will be audited daily on each shift by Med Tech. This will be audited throughout the week by management (ED, RSC, RSD, Lead Med Tech).
4. The RSC will be responsible for ensuring this is completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure any incident of abuse or suspected abuse was reported to the local SPD office or the local AAA, promptly investigated all reports of abuse and suspected abuse and took measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#10) who incidents were reviewed. Findings include, but are not limited to:
Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia.
The resident's 09/20/24 service plan, 09/09/24 through 09/24/24 progress notes, an incident report, and Temporary Service Plans (TSP)'s were reviewed, and observations and interviews were conducted.
The facility failed to immediately report abuse or suspected abuse to the local SPD office and promptly investigate all reports of abuse and suspected abuse for the following incident:
09/09/24 - Progress notes indicated Resident 10 was sitting on the couch in another resident's room when the Activity Director entered with one of the residents who occupied that room. When s/he was asked "politely" by staff to leave, Resident 10 began yelling and knocked the staff to the floor. "The other resident in the living room tried to intervene by yelling at [him/her] to stop before [Resident 10] got up in [his/her] face as well [sic] threatening to do something about [him/her] next."
On 09/25/24 at 10:35 am, an interview with Staff 1 (ED) indicated she was not working at the time and confirmed the incident was not reported to the local SPD office.
On 09/25/24 at 10:45 am, an interview with Staff 2 (LPN/Resident Services Coordinator), who was covering at the time, confirmed there was no investigation and he had not completed "a TSP because by the time I got there the residents had been separated out of that room", Resident 10's spouse got him/her to leave the room "and [Resident 10] was fine".
The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigated was discussed with Staff 1 and Staff 2 on 09/25/24 at 12:00 pm. They acknowledged the findings.
On 09/25/24, survey requested the facility report the incident to the local SPD office, verification was received prior to exit.
1. This was immediately reported to APS prior to survey exit.
2. Retraining was completed with RSC and ED regarding Resident, Abuse and Reporting.
Retraining was completed with all staff regarding their responsibility of accurately reporting and documenting resident behaviors.
3. Progress notes will be reviewed daily by the Resident Services Coordinator/Resident Services Director as well as the ED to ensure that the proper documentation and investigations are completed in a timely manner.
An audit log will be created and used to verify the prog notes are being reviewed daily.
4. The Executive Director is responsible for ensuring that this is completed and monitored.
Based on observation, interview and record review, it was determined the facility failed to investigate an injury of unknown cause or unwitnessed fall to rule out possible abuse or report to the local SPD office if abuse could not be ruled out for 1 of 2 sampled residents (#11) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 11 was admitted to the memory care facility in 08/2023 with diagnoses including dementia.
a. During the acuity interview on 12/30/24, the resident was identified as requiring full assistance with all ADLs, including a two-person assist for transfers and 1:1 assistance during meals.
On 12/30/24 at 11:07 am, the resident was observed with a dressing on the left elbow area.
A 12/24/24 Skin Impairment note showed "skin tear noted to left elbow".
There was no documented evidence the facility conducted an investigation to determine the cause of the skin injury. The incident was not reported to the local SPD office. The surveyor requested Staff 1 (ED) and Staff 2 (Residential Services Coordinator, LPN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit.
b. The resident's clinical record dated 11/01/24 through 12/19/24, and an 11/15/24 incident report were reviewed during the survey and revealed the following:
* 11/15/24 progress note: "Resident on alert for an unwitnessed fall ..."; and
* 11/15/24 incident report: the resident was found on the floor next to his/her bed. It appeared the resident slid off the side of the bed due to not being positioned properly in the center of the bed.
The service plan dated 11/21/24 instructed staff to ensure the resident was positioned in the center of the bed before leaving the room after providing care. The plan was implemented on 10/11/24.
There was no documented evidence indicating the facility determined how the incident was ruled out as abuse or neglect, especially since staff did not follow the service plan. The incident was not reported to the local SPD office. The surveyor requested Staff 1 (ED) and Staff 2 (Residential Services Coordinator, LPN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit.
The need to ensure injuries of unknown cause and unwitnessed falls were immediately investigated by the facility, and if abuse was not able to be reasonably ruled out, the incidents were reported to the local SPD office, was discussed with Staff 1, Staff 2 and Staff 3 (Lead MA) on 12/31/24 at 11:25 am. They acknowledged the findings.
1. Skin tear was reported to APS prior to Survey exit.
2. Retraining was completed with RSC regarding incident investigation and documentation of investigation.
3. Resident Service Director will be directly involved in any incident investigation to rule out abuse. She will assist in ensuring that investigation is complete and APS is notified in any instance that abuse can not be ruled out.
4. The Executive Director will be responsible for ensuring that this is completed and monitored .
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed. Findings include, but are not limited to:
Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.
The Move-In Evaluation, dated 03/29/24, was reviewed and revealed missing information in the following required elements:
* Customary routines regarding sleeping, eating, and bathing;
* List of medications and PRN use;
* Personality including how the person copes with change or challenging situations;
* Ability to understand and be understood;
* Non-pharmaceutical interventions for pain;
* Nutrition habits, fluid preferences, and weight if indicated; and
* Complex medication regimen.
The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) on 07/10/24. She acknowledged the findings.
The facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled
resident (#7) whose evaluation was reviewed.
1. Current evaluation was updated with the missing information.
2. In the future, we will be using the resident review form for all new move-ins to ensure that all of the required elements are met.
3. This will be reviewed by both the RN and LPN at time of move-in and at 30-day review. Executive Director or designee will audit all new admissions weekly for a period of three months to ensure all required elements were addressed.
4. The Executive Director and RN will be responsible to ensure these corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 11/2017 with diagnoses including dementia.
The resident's service plan, dated 06/26/24, and Temporary Service Plans were reviewed. Resident 3 was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas:
* Ability to take self to the restroom;
* Interventions when the resident yelled at the roommate;
* How Resident 3 communicated when other residents were getting too close to him/her;
* Changing staff members when the resident was reluctant to receiving care;
* Ability to get self ready for bed; and
* Where the resident preferred to eat their meals.
The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.
2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including dementia.
The resident's service plan, dated 06/24/24, Temporary Service Plans and progress notes, dated 04/09/24 through 07/05/24, were reviewed. The resident was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas:
* Apartment door alarm;
* Hearing; and
* Toileting assistance.
The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.
The facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services
for 2 of 5 sampled residents (#s 3 and 6) whose service plans were reviewed.
1. Current service plans for residents identified have been reviewed and updated with the current needs and/or clear caregiving instruction in the areas that were not meeting the requirements.
2. Nursing staff will review all service plans to ensure all of the required elements are met.
3. This will be reviewed at time of move-in, 30-day review, as well as quarterly by the Lead Med Tech, RN and/or LPN as well as the Service Planning team (family, care staff, etc.). The Executive Director or designee will audit five service plans weekly for a period of three months to ensure plans correlate with resident evaluations, are complete and provide clear instructions for care staff.
4. The Executive Director and RN will be responsible for ensuring that these corrections are 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 and preferences, provided clear direction regarding the delivery of services, and services were implemented for 2 of 4 sampled residents (#s 8 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
1. Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia.
Observations of the resident, interviews with staff and review of the most recent service plan, dated 09/23/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas:
* Use of heel protectors and pillow between legs for skin integrity when in bed;
* Use of washcloth in contracted hand;
* Positioning in the wheelchair for comfort and skin integrity from rigid footplates; and
* How long to be sitting up in the wheelchair.
The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.
2. Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia.
Observations of the resident, interviews with staff and review of the most recent service plan, dated 09/20/24, and a Temporary Service Plan (TSP), dated 09/11/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:
* Non-pharmacological interventions for pain and location of the pain;
* Resident-specific behavioral interventions for prevention of further resident to resident behaviors; and
* Showering schedule including preferences for time of day.
The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.
1A. Resident 8's service plan was updated to include:
a. use of heel protectors and a pillow between her legs for skin integrity when in bed.
b. use of washcloth in contracted hand to prevent yeast.
c. Reposition while in wheelchair to maintain skin integrity and comfort.
1B. Resident 10's service plan was updated to include:
a. Use of ice to relieve pain in knees/ankles. His wife will occasionally bring in and apply aspercream on his knees/ankles.
b. If staff see Dale becoming agitated, they should be separated before any altercation occurs if possible. If Dale is showing signs of agitation as evidenced by 1) yelling 2) combativeness 3) slamming doors, staff are to attempt non medical interventions such as 1) offer to go on a walk 2) offer a snack or some pink lemonade. 3) separate Dale from other residents and help him find a quiet area. If interventions are ineffective after 15 minutes, administer
c. Dale will be showered 1 to 2 times weekly as he will tolerate. Wife states that Dale prefers to shower after his breakfast and medications.
2. Retraining was provided to all staff regarding changes in ADL care and reporting changes in ADL care to management.
Care staff and/or lead med tech will be present for each service plan to ensure that care needs, preferences and interventions are accurately reflected in each service plan.
3. The Resident Services Coordinator, Lead Med Tech and ED will audit service plans weekly to ensure they are meeting all of the required and are accurate according to care needs.
An audit tool has been created and will be used while reviewing resident service plans.
3. The Executive Director will be repsonsible for ensuring these are completed and monitored.
Based on observation, interview and record review, it was determined the facility failed to ensure the implementation of service for 1 of 2 sampled residents (#11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 11 was admitted to the facility in 08/2023 with diagnoses including dementia.
During the survey, the resident was observed to have contractions in the right hand, with the fingers tightly clenched and the hand fixed in a fist like position. Additionally, the resident was transferred with the assistance of two staff who placed their arms under the resident's armpits during the transfer.
Observations of the resident, interviews with staff, and the 11/21/24 service plan reviewed during the survey showed staff did not implement the outlined service plan in the following areas:
* Transfer status including the use of a gait belt; and
* Place a cloth in the right hand to help prevent yeast build up.
On 12/31/24 at 11:25 am, not implementing the outlined service plan was discussed with Staff 1 (ED), Staff 2 (Residential Services Coordinator, LPN) and Staff 3 (Lead MA). They acknowledged the findings.
1. Staff immediately placed protective cloth in hand to prevent yeast build-up.
Staff were counseled on use of gait belt and following service plan.
2. All-staff training was completed on reviewing and following service plans. Staff were instructed to re-read all service plans and sign off stating they read and understand.
3. Resident Services Director and ED will audit staff performing ADL's multiple times per week on different shifts to ensure that they are meeting all aspects of the service plan. This will be tracked on an audit form to ensure that this is happening and that it is corrected. Service plans will be reviewed for staff signatures and quizes of service plans will be conducted weekly with random staff.
4. Executive Director will be responsible for ensuring that this is completed and monitored.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#8) who was observed receiving ADL care at bedside and meal assistance. Findings include, but are not limited to:
Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia.
The current service plan, dated 09/23/24, identified the resident had the following care needs:
* Feeding assistance from staff;
* Two-person assist for transfers using a hoyer lift; and
* Full assist with toileting and perineal care.
a. On 09/24/24, meal observations were conducted in the facility's activities room, which served as a secondary dining area.
At 12:16 pm, Staff 9 was observed handling a resident's soiled plate with the thumb of her ungloved left hand on the surface of the plate. When she returned the plate to the table, she picked up the resident's used cup with the ungloved left hand, placing her fingers near the rim of the cup. After Staff 9 returned the cup to the resident, she sat next to Resident 8, picked up a napkin with the ungloved left hand and began wiping Resident 8's mouth with the napkin. Staff 9 was not observed to have preformed hand hygiene after handling the soiled dishware and prior to assisting Resident 8.
On 09/25/24, the need to ensure staff used universal precautions when providing care to residents was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator). They acknowledged the findings.
b. During an ADL observation with Resident 8 on 09/24/24 at 11:05 am, the following was observed:
* Three caregiving staff donned gloves and assisted the resident with incontinence care, which included physical assistance with rolling, perineal care, and repositioning;
* All three staff assisted in removing the soiled brief;
* One staff provided perineal care that included using wipes. All three staff then touched a clean incontinence brief, the resident's legs and torso, clothing, heel protectors, the bedding, and the hoyer sling, all while wearing the soiled gloves;
* The staff who cleaned the perineal area then used the controls of the hoyer lift while the other two staff touched the handles, back and footplate's of the wheelchair; and
* The staff who cleaned the perineal area removed the soiled gloves and performed hand hygiene prior to leaving the resident's room. The other two staff remained in the room and made the resident's bed and assisted Resident 8's roommate who was also in the room without changing soiled gloves.
The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.
1. Staff 8, 9 and 22 were immediately retrained on infection control.
2. Infection control training was held for the entire staff. The importance of proper use of gloves and handwashing was stressed to every staff member. An additional Infection Control Specialist has joined the management team and will assist with on-going training.
3. This will be audited daily on each shift by Med Tech. This will be audited throughout the week by management (ED, RSC, RSD, Lead Med Tech).
4. The RSD will be responsible for ensuring this is completed and monitored.
2a. During an ADL observation on 12/30/24 from 1:03 pm to 1:14 pm the following was noted:
The surveyor obtained permission and observed Staff 12 (CG) and Staff 16 (CG) provided incontinence care to Resident 11. Both staff wore single-use gloves while assisting the resident with transferring from the wheelchair to the bed. The staff then helped with personal care by removing a soiled brief, cleaning the perineal area and putting on a clean brief using the same gloves. The staff then touched the resident's blanket, assisted with dressing the lower body, and transferred the resident from the bed to the recliner while wearing the same gloves. During the observation, both staff did not change their gloves or wash their hands between clean and dirty tasks.
2b. During an observation on 12/31/24 from 11:04 am to 11:12 am the following was noted:
The surveyor obtained permission and observed Staff 13 (CG) and Staff 23 (CG) provide incontinent care to Resident 11. Staff 23 removed the resident's soiled brief and removed the gloves, then used hand sanitizer to clean their hands before putting on a new pair of gloves. Afterward, Staff 13 and Staff 23 assisted the resident with repositioning and lower body dressing. However, after removing the soiled brief, the resident's perineal area was not cleaned or wiped. Both staff assisted the resident with putting on lower body clothing including a clean brief and pants after removing the soiled brief without cleaning the resident's perineal area.
The need to ensure proper infection control was utilized during the incontinence care and hand hygiene was discussed with Staff 1 (ED), Staff 2 (Residential Service Coordinator, LPN) and Staff 3 (Lead MA) on 12/31/24 at 11:25 am. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary environment for 1 of 2 sampled residents (# 11) and 1 of 1 unsampled residents who received incontinence care. This is a repeat citation. Findings include, but are not limited to:
1. During an ADL observation on 12/30/24 at 1:50 pm the following was noted:
Staff 12 (CG) and Staff 24 (CG) donned their gloves and assisted an unsampled resident to the bathroom. Staff 24 assisted the resident to remain standing while Staff 12 doffed the resident's pants, removed the soiled brief, put it in the trash can, and removed the resident's soiled pants. Staff 24 assisted the resident to sit on the toilet. Without changing the soiled gloves or performing hand hygiene, Staff 12 assisted the resident with a clean brief and clean pants. Both caregivers then doffed their soiled gloves, and assisted the resident to stand up. The caregivers were observed leaving the resident's apartment, and then going to another room. There was no observation of hand hygiene.
The need to ensure proper infection control and hand hygiene was utilized during incontinence care was discussed with Staff 1 (ED), Staff 2 (Residential Service Coordinator, LPN), and Staff 3 (Lead MA) on 12/31/24. They acknowledged the findings.
1. Staff 12, 24 were immediately re-trained and quizzed on proper handwashing and use of gloves.
2. Infection control training was held for staff on each shift in a smaller environment and staff competency was completed with all staff to ensure they know and understand the use of gloves and handwashing.
3. This will be audited daily on each shift by Med Tech, RSC and lead med tech. Infection Control Specialist will be observing to ensure this audit is occuring and that staff are using correct infection control.
4. Executive Director will be reponsible for ensuring this is completed and monitored ongoing.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 07/2023 with diagnoses including dementia and chronic obstructive pulmonary disease.
The resident's 06/01/24 through 07/08/24 MARs and physician orders were reviewed. The following was identified:
* The resident had a physician order for Hydrocod/APAP 5/325 mg tab, one tablet every six hours as needed for severe pain.
* The 06/01/24 through 07/08/24 MAR revealed the resident was administered the PRN narcotic on 31 occasions in 06/2024 and on nine occasions between 07/01/24 and 07/08/24.
* The Controlled Substance Distribution log contained nine entries for 06/2024 and five entries for 07/2024, which were not reflected on the MARs.
* The number of tablets remaining noted in the Controlled Substance Distribution log matched the number of tablets remaining on the corresponding medication cards.
The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.
The facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication.
1. All controlled substances distribution logs have been audited and any discrepencies have been documented and entered in to the MAR.
2. Retraining will be completed with all current med techs and new med techs prior to working on the med cart to ensure that they are aware of the policy and are documenting correctly.
3. Audits of the controlled substance distribution logs to the MAR will be completed weekly by the Resident Service Coordinator and/or the Lead Med Tech. Any discrepencies will be reported to the RN and Executive Director. RN will perform random audits of the CS logs 2x/month for three months to ensure staff are following the policy and procedure.
4. The RN will be responsible to ensure that these corrections are completed/monitored.
There are no detail notes for this visit.
2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including dementia.
The resident's 06/01/24 through 07/08/24 MARs, physician's orders, and progress notes, dated 04/09/24 through 07/05/24, were reviewed. The following was identified:
a. There were medications which were not initialed as administered with no indication whether or not the medication had been administered for the following dates and times:
* 06/24/24 at 8:00 am: Buspirone (for sexual behaviors), Eliquis (for atrial flutter), Lisinopril (for hypertension), metoprolol (for atrial flutter and hypertension), and
sertraline (for dementia); and
* 07/01/24 at 8:00 am: Sertraline.
b. Staff documented the resident's buspirone could not be administered as they were "waiting on delivery" from 06/22/24 through 06/26/24 and from 06/30/24 through 07/03/24. Staff initialed the MAR indicating the buspirone was administered nine times during the dates that the medication was not available.
The need to ensure the accuracy of MARs was discussed with Staff 1 (ED) on 07/10/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 06/2021 with diagnoses including dementia.
The resident's 06/01/24 through 07/08/24 MARs were reviewed. The following was identified:
* On 06/26/24 there were seven medications which were not initial as administered at 8:00 pm. There was no indication whether or not the medication had been administered.
In an interview on 07/11/24 at 9:35 am, Staff 1 (ED) and Staff 3 (Lead MT) stated it was "probably" the MT working that shift "got busy" and neglected to enter the administration time in the electronic MAR.
The need to ensure all medication administered to residents was documented accurately in the MAR was discussed with Staff 1 and Staff 2 on 07/11/24. They acknowledged the findings.
The facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed.
1. All missing signatures were corrected.
2. Retraining will be completed with all current med techs and new med techs prior to working on the med cart.
3. Review of the MAR will be completed at the end of each shift by Med Techs to ensure documentation is complete. Lead Med Techs will perform a MAR audit for five residents once a week. The Resident Services Coordinator (LPN) or designee will run and review the Medication Administration Audit Report 2x/week for three months and follow up on any missed medications or documentation. Findings will be reported to the RN.
4. The RN will be responsible to ensure that these corrections are completed/monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:
Review of fire drill and fire and life safety records for 01/2024 through 07/2024 identified the following:
a. The fire drill records lacked documentation of the following components:
* Location of simulated fire origin;
* Escape route used; and
* Problems encountered.
b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills and the content of the training was related to fire and life safety.
On 07/11/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (ED) and Staff 3 (Lead MT). They acknowledged the findings.
The facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months.
1. Fire Drill records identified were updated to include missing information from drills conducted.
2. Retraining was completed with the Environmental Services Director.
3. Fire Drills are scheduled every other month and will be conducted by Exec. Director and Environmental Services Director. Fire and Life Safety education will be completed on alternate months and clearly documented. The Executive Director will track all Fire Drill and Fire and Life Safety education documentation to ensure it is complete.
4. The Executive Director will be responsible for ensuring this is completed.
There are no detail notes for this visit.
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 C260.
Refer to C260
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. This is a repeat citation. Findings include but are not limited to:
Refer to C231, C260, and C295.
See C231, C260, C295
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 420.
See POC C 420.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C200, C231, and C295.
Refer to C200, C231 and C295
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C231 and C295.
See C231 and C295
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:
Refer to C 252, C 260, C 302, and C 310.
See POC C 252, C 260, C 302 and C 310.
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C260.
Refer C260
Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C260.
See C260
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:
Residents 1, 2, 3, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.
The need to develop a daily meal program based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.
The facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and
hydration plans were reviewed.
1. All identified resident service plans were updated to give information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the residents. A daily meal program based on resident preferences was included in their service plans.
2. All resident service plans will be reviewed and updated to reflect their individualized nutrition and hydration status, preferences and needs.
3. This will be evaluated at every service plan meeting including move-in, 30-day, quarterly and as needed. The RN or designee will audit five service plans weekly for a period of three months to ensure appropriate, individualized nutrition and hydration preferences and plans are outlined in the service plan.
4. The Executive Director and RN will be responsible for ensuring this is completed and monitored.
There are no detail notes for this visit.