The findings of the re-licensure survey, conducted 10/16/23 through 10/18/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 10/18/23, conducted on 02/20/24 through 02/21/24, 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 interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

During interviews with sampled and un-sampled residents on 10/17/23, residents reported the following concerns:

* Property theft was not addressed "for months", and was only addressed after it was reported to the Ombudsman by the resident; and

* Ongoing circuit breaker tripping in a resident apartment was not resolved.

In an interview on 10/18/23, Staff 1 (ED) stated he was actively involved in following up on both incidents but had no documented evidence the complaints had been addressed. He reported his process of responding to resident concerns was to address them immediately, rather than document in the grievance binder.

The need to ensure the facility had an effective method of responding to and resolving resident complaints was discussed with Staff 1 and Staff 3 (Maintenance Director) on 10/18/23. They acknowledged the findings.

OAR 411-054-0025 (7) Facility

Administration: Policy & Procedure

1. What actions will be taken to correct the rule violation for each example are as follows:

 a. Education provided to Executive Director on company policy for grievances and protocol on documentation for resolving and responding to resident complaints

 b. Grievance binder prepared with appropriate forms for documentation

 c. Grievance policy reviewed with residents for proper reporting- theft resolved, circuite breaker has been repaired

2. How will the system be corrected so this violation will not happen again are as follows:

 a. All Department Managers will have training on grievance policy and use of grievance binder and forms for times when ED not present.

3. How often will the area needing correction be evaluated are as follows:

 a. Daily when needed by ED until resolution is completed.

 b. Weekly review with ED and Direcor of Operations during 1x1 until resolution of grievance

4. Who will be responsible to see that the corrections are completed/monitored are as follows:

 a. Executive Director

 b. Director of Operations with ED 1x1 will review for compliance   

Based on observation, interview, and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and neglect and reported to the local SPD office when required, for 1 of 2 sampled residents (#3) reviewed with incidents. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2021 with diagnoses including chronic pain.  

Observations of the resident, interviews with staff, review of the resident's 10/05/23 service plan, 07/01/23 through 10/14/23 temporary service plans, progress notes, physician communications, and incident investigations were completed.

The resident was able to direct his/her own care to a degree, was very forgetful with increased confusion. The resident required extensive assistance from staff for all care. The resident's spouse lived with him/her and would frequently refuse care and/or medications on behalf of the resident regardless of what Resident 3 expressed. The resident was admitted to hospice in late July 2023 due to a rapid decline in condition, increased weakness, and confusion.

Review of the resident's records showed the following:

* A progress note dated 09/18/23, indicated the resident used the call light to request Tylenol due to abdominal pain. The note further indicated the resident's spouse had two Tylenol in the room at the time and indicated they belonged to Resident 3. The spouse wanted Resident 3 to take them. The MT took the medication from the spouse and administered them to Resident 3. "MT did not pull PRN from cart."

There was no other information about the medications that were administered to the resident. No investigation was completed about the incident to determine why medications were not administered from the cart, how the medication ended up in the room, confirmation of what it was and why the MT staff would administer it to Resident 3 after accepting it from the resident's spouse.

In an interview on 10/18/23, Staff 2 (RCC) indicated she was not made aware of the issue and had no idea medications were given that were not from the facility medication cart. Staff 3 further indicated the incident should have been investigated. The facility has requested the family remove medications from the resident room on several occasions as the spouse had a history of attempting to give medications to Resident 3.

In an interview on 10/18/23, Staff 1 (ED) indicated he was not aware of the specific incident but was aware of ongoing concerns regarding Resident 3's spouse interfering with resident care and medications. Staff 1 was asked to report the incident to the local SPD office.

A confirmation of the report was provided to the survey team prior to exit.

The need to ensure incidents were investigated promptly to rule out abuse and neglect and reported to the local SPD office when required, was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/18/23. The staff acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

1. What actions will be taken to correct the rule violation for each example/resident:

a. The incident on 9/18/23 regarding Resident #3 PRN medication administration was reported to SPA and confirmation was provided to survey team.

b. ED will meet with family of Resident #3 to discuss OTC medications that are in Resident #3 room and discuss actions of residents husband regarding administering medications and care services. ED will document this meeting and subsequent conversations.

c. An investigation into the administration of PRN medications for Resident #3 has been conducted by the ED.

2. How will the system be corrected so this violation will not happen again?

a. The Med Techs will be retrained on the policy and procedure for administering PRN medications from the medication cart.

b.  ED or Wellness Director  will train all care staff  on reporting incidents and investigating incidents to rule out abuse/neglect.  ED will maintain records for this training.

c. All incidents will be reported to the RN and/or ED immediately by the care staff or med tech and noted in the 24 hour communication log and the resident chart using a chart note.

d. The RN and/or RCC will review each incident and conduct an investigation of the incident to determine the abilty to rule out  abuse and neglect.  

e.  All incidents that abuse and/or neglect cannot be ruled out will be reported to SPD or local APS and local law enforcement agency.

3. How often will the area needing correction be evaluated?

a. All incidents will be reviewed with the ED during stand up meetings daily Monday - Friday and SMART meetings. This review will include review of the incidents, notifications, documentation of incident, interventions put in place and outcome or follow up.

4. Who will be responsible to see that the corrections are completed/monitored?

a. Executive Director will monitor this process for compliance during SMART meetings held Monday through Friday each week. SMART meeting notes are maintained on the Seasons Dashboard.

b. Executive Director will keep a binder of all incidents.

c. SMART meeting minutes are maintained on the Season Dashboard.

2. Resident 1 was admitted to the facility in 10/2019 with diagnoses including stroke.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 08/14/23 and progress notes dated 07/20/23 to 10/09/23 were completed. Staff indicated the resident required extensive assistance with all care and was very weak. The resident could make his/her needs known but had significant difficulty with shortness of breath and weakness. The resident's service plan was not reflective and lacked resident specific direction for staff in the following areas:

* Pet care;

* Transfer assistance and non-skid footwear use;

* Bed mobility;

* Repositioning in the wheelchair/recliner and pillow use;

* Dressing and bathing assistance;

* Chronic, recurring skin breakdown;

* Side rail use and safety checks; and

* Incontinent care and toileting needs.

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) and Staff 2 (RCC) on 10/18/23. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 10/2021 with diagnoses including hypertension and chronic back pain.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/05/23 and progress notes dated 07/01/23 to 10/14/23 were completed. Staff indicated the resident required extensive assistance with all ADL care. The resident sometimes needed two staff assistance for care when weaker or more tired. The resident could make some needs known but had experienced increased confusion. The resident's spouse, who lived with the resident, was very involved in care and would frequently decline care or request medications on behalf of the resident when Resident 3 expressed no concerns. The resident's service plan was not reflective and lacked resident specific direction for staff in the following areas:

* Side rail use, positioning in bed and ensuring the rail was secure;

* Evacuation assistance;

* Hearing aide use and charging of hearing aides;

* One person vs. two person transfers;

* Manual wheelchair vs. walker use;

* Ambulation assistance and transfer needs;

* Incontinent care;

* Dressing, grooming and hygiene assistance; and

* Swallowing precautions, food textures, fluid intake and meal assistance.

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) and Staff 2 (RCC) on 10/18/23. The staff acknowledged the findings.

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

1. Resident 4 was admitted to the facility in 11/2020 and was receiving hospice services for end of life care.

Observations of the resident, interviews with staff from 10/16/23 to 10/18/23, review of the service plan and evaluation dated 08/21/23, ADL worksheets, progress notes, and interim service plans were completed. The resident could make his/her needs known but had significant difficulty with weakness. 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:

* The use of siderails including risks and precautions; and

* Adaptive silverware for eating.

The need to ensure residents' service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/16/23 and 10/17/23. They acknowledged the findings.

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

1. What actions will be taken to correct the rule violation for each example/resident?

a. Resident #4 service plan will be reviewed and updated to accurately reflect the residents status and specific instructions to staff including

*The use of siderails including risks and precautions and

*adaptive silverware for eating.

b. RN will review all residents service plans who utilize siderails or other supportive  devices to ensure the service plans accurately reflect the residents use of supportive  devices and include specific instructions to staff.

c. All residents who use siderails or other supportive  devices will have a Supportive Device Safety Evaluation completed and added to the chart along with any needed service plan updates.

d. Resident #1 service plan will be reviewed and updated to accurately reflect the residents status and specific instructions to staff including:

*Pet care

*Transfer assistance

*Non skid footwear

*Bed mobility

*Repositioning in the wheelchair/recliner and pillow use

*Dressing and bathing assistance

*chronic and recurring skin breakdown

*Side rail use and safety checks

*Incontinent care and toileting needs.

e. Resident #3 service plan will be reviewed and updated to accurately reflect the residents status and specific instructions to staff including:

*Side rail use, positioning in bed and ensuring the rail is secure

*Evacuation assistance

*Hearing aide use including charging of hearing aids

*One person vs. two person transfers

*Manual wheelchair use and walker use

*Ambulation assistance and transfer needs

*Incontinence care

*Dressing, grooming, and hygiene assistance

*Swallowing precautions, food textures, fluid intake and meal assistance.

f. All resident service plans will be reviewed for content and updated where needed to include staff instruction

2. How will the system be corrected so this violation will not happen again?

a. The RN will attend the Role of the RN class (current agency RN has attended).

b. RN, RCC and Executive Director will review each element of the evaluation/service plan during each service plan update to ensure content is accurate and ensure all resident needs are addressed prior to signing off on  the service plan.

c. RN and RCC will collaborate to ensure that all resident care needs are identified in all service plan updates and include specific staff instructions regarding care needs.

3. How often will the area needing correction be evaluated?

a. Each service plan update will be reviewed for content by the Executive Director prior to signing the new service plan.

b. Quarterly and COC service plan updates will be reviewed during each SMART meeting Monday through Friday.  SMART meeting minutes are maintained on the Seasons Dashboard.

4. Who will be responsible to see that the corrections are completed/monitored:

a. Executive Director will review each service plan for content and provide feedback as necessary prior to signing off on all service plans.

Based on observation, interview, and record review, it was determined the facility failed to ensure short term changes of condition had weekly progress documented through resolution, interventions were monitored according to evaluated needs and  new actions or interventions including resident specific directions were provided to staff for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2019 with diagnoses including stroke.

Observations of the resident, interviews with staff, and review of the resident's service plan dated 08/14/23 and progress notes dated 07/20/23 to 10/09/23 were completed.

The resident experienced multiple short-term changes without documented progress at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas:

* Nausea and vomiting;

* Pain to the lower back and bottom;

* Chronic, reoccurring redness and open area to coccyx; and

* Rash to the back.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and clear, resident-specific directions were provided to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/18/23. The staff acknowledged the findings.  

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including hypertension and chronic back pain.  

Observations of the resident, interviews with staff, and review of the resident's service plan dated 10/05/23 and progress notes dated 07/01/23 to 10/14/23 were completed.

The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Injury and non-injury falls;

* Chest pain, abdominal pain, and genital pain;

* Nausea and vomiting;

* Multiple medication changes;

* Urinary tract infection and antibiotic use;

* Suicidal statement;

* Medication errors; and

* Sore in the mouth.

The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution, interventions were evaluated for effectiveness, and clear, resident-specific directions were provided to staff was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/18/23. The staff acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. What actions will be taken to correct the rule violation for each example/resident:

a. Resident #1 will be evaluated by the RN for Nausea, vomiting, pain, and skin condition and the service plan will be updated to reflect these changes.

b. A full skin assessment will be conducted by the RN on resident #1 and resident #3.

c. A pain evaluation will be completed by the RN on resident #1 and resident #3.

d. Resident #3 will be reviewed by the RN for falls, complaints of pain, medication changes, UTI and antibiotic use, suicidal statements, medication errors and mouth sores and service plan will be updated to reflect these changes.

e. RN will enter updated change of condition notation on both resident #1 and resident #3.

f. All resident service plans will be reviewed for accuracy and updated where needed.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the role of the RN class (current agency RN has attended).

b. All care staff will be trained on change of condition identifiers and reporting of changes.

c. Change of Condition Interpretive Guidelines given to the RN for review and reference.

d. Executive Director and RN will have weekly one on one meetings to identify and discuss resident changes.

e. RN will make weekly notes on residents with change of condition until resident is stable.

f. All residents with changes will be reviewed during SMART meetings Monday through Friday to ensure COC is addressed.

g. All residents identified as having a change of condition will have an ISP put in place for immediate staff instruction and will be placed on alert charting until RN weekly notes are in place.

3. How often will the area needing correction be evaluated:

a. Weekly during ED, RN one on one meetings to review residents at risk, resident changes and coordination of care, including weekly review of chart notes.

4. Who will be responsible to see that the corrections are completed/monitored?

a. ED and RN during weekly one on one meetings

b. ED during SMART meetings Monday through Friday.

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

Resident 3 was admitted to the facility in 03/2021 with diagnoses including hypertension and chronic pain.  

Weight records, dated 05/21/23 through 08/23/23 and progress notes, dated 07/01/23 through 10/14/23, indicated the resident experienced the following:

* A 9.2-pound loss between 07/21/23 and 08/23/23, which constituted a 6.31% severe loss in a month.

* A 13.8-pound weight loss between 05/21/23 and 08/23/23, which constituted a 9.18% severe weight loss in three months.

No weights were available after 08/23/23 due to resident and/or spouse refusal to allow. An attempt for care staff to get a current weight at the time of survey was unsuccessful due to resident/spouse refusal.

Progress notes, temporary service plans, and physician communications dated 07/01/23 through 10/14/23 indicated the resident was independent with meals and ate only in his/her apartment with their spouse. The resident required mechanical soft items that were cut up for easy chewing and swallowing. The resident was admitted to hospice services on 07/24/23 related to increased confusion and weakness. The resident required more assistance from staff for care related to the decline in condition.

No RN assessment of the decline in condition was completed at the time of the hospice admission.   

Observations of the resident between 10/16/23 and 10/17/23 showed the resident up in the recliner in his/her room for all meals. The resident was observed to eat between 25% and 75% of foods and fluids that were provided. The resident was provided his/her foods cut up and was able to eat independently once delivered.  

Interviews with staff and the resident on 10/16/23 and 10/17/23, showed the following:

Resident 3 indicated s/he received plenty to eat, and s/he stated it tasted fine. The resident pointed out fluids on the side table next to him/her. The resident expressed no concerns with the care and assistance staff provided.

Resident 3's spouse indicated they both received plenty to eat. S/he was pleased with how the kitchen worked to give them items that were tasty and they could each swallow and chew without issue. The resident was now on hospice because s/he was getting weaker and declining.

Staff 9 and Staff 10 (Agency Resident Assistants) indicated the resident ate in his/her apartment for all meals. Once the meal items were delivered the resident was able to eat on his/her own. Staff 9 indicated the resident's intake varied depending on how his/her stomach felt. The staff indicated the resident needed 1-2 staff assistance for ADL care. The resident continued to attempt self-transfers without calling for staff assistance and was a high fall risk.

Staff 2 (RCC) indicated the current RN was new to the facility and had been out of the facility the last several days. Staff 2 stated she had previously made a note related to the resident's weight loss and reported it to the RN at the time. The resident's intake varied as s/he was sometimes nauseated. Staff 2 stated the resident was recently placed back on hospice as his/her decline had increased.

No RN assessment could be located for the severe weight loss or hospice admission.

The facility failed to ensure an RN assessment was completed for the weight loss from July 2023 to August 2023 and the hospice admission in July 2023 which documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/17/23 and 10/18/23. The staff acknowledged the findings.  

OAR 411-054-0045 (1) (a-f) (A) (C-F) Resident Health Services

1. What action will be taken to correct the rule violation for each example/resident?

a. Resident #3 chart and service plan will be reviewed for weight changes and reported to the physican.

b. Resident #3 will have appropriate interventions put in place to address weight loss along with physician notification.

c. Resident #3 decline in condition and hospice admission, fall risk,  and dietary needs will be added to service plan.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend Role of the RN class (Current agency RN has attended class)

b. RN will complete a new assessment for any resident who has a change of condition and update the service plan to reflect changes.

c. All residents with changes in condition will be placed on alert charting and an ISP for staff instruction will be put in place until concern is resolved or new baseline is established.

d. RN will enter change of condition documentation weekly until baseline is established.

e. RN and ED will discuss resident changes during weekly one on one meetings to ensure process is followed.

f. Care staff will be trained on use of the care plan addendum tool for identifying changes in residents and reporting changes noted.

g. Med Techs will be trained on placing residents on alert charting and review of guidelines for when to place a resident on alert charting.

3. How often will the area needing correction be evaluated?

a. All ISP's and alert charting will be reviewed daily during SMART meetings Monday - Friday.

b. Weekly during ED/RN one on one meetings.

4. Who will be responsible to see that the corrections are completed/monitored?

a. ED and RN during weekly one on one meetings and daily SMART meetings Monday - Friday.

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 2 of 3 sampled residents (#s 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2020 and was receiving hospice services.

The resident's 09/01/2023 through 10/16/2023 MARs were reviewed and revealed:

* PRN bowel medications (Senna 8.6, MiraLax 17 gram, and Bisacodyl Suppository 10 mg) lacked clear instruction to staff regarding the order of administration.

* PRN pain medications (Oxycodone 5 mg and Acetaminophen 160 mg solution) lacked clear instruction to staff regarding the order of administration.

2. Resident 5 was admitted to the facility in 02/2021 with diagnoses of chronic obstructive pulmonary disease.

The resident's 09/01/2023 through 10/16/2023 MARs were reviewed and revealed:

* PRN breathing treatments (Albuterol Sulfate nebulizer and Ventolin inhaler) lacked clear instruction to staff regarding the order of administration.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/16/23 and 10/17/23. They acknowledged the findings.

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

1. What actions will be taken to correct the rule violation?

a. Resident #4 and #5 PRN medications will be reviewed by the rN and order of administration wil lbe assigned for PRN medications that are ordered for the same diagnosis.

b. All residents PRN medications will be reviewed by the RN and order of administration will be assigned for PRN medications that are ordered for the same diagnosis.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the Role of the RN class (current agency nurse has attended this class)

b. All new medication orders will be reviewed by the RN for accuracy and order of administration will be entered for all PRN medications given for the same diagnosis.

3. How often will the area needing correction be evaluated?

a. Quarterly with quarterly medication reviews.  All resident orders will be reviewed by the RN and then  will be sent to the physician for review and signature, then faxed to the pharmacy and filed in the residents chart.

4. Who will be responsible to see that the corrections are completed/monitored.

a. RN during each medication reconciliation review.

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed thoroughly by an RN, PT, or OT prior to use for 3 of 3 sampled residents (#s 1, 3, and 4) who had side rails. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2019 with diagnoses including stroke.

Observations of the resident, interviews with the resident and staff, and review of the service plan dated 08/14/23 showed the resident had half side rails on each side of the bed, at the head of the bed. The resident required extensive assistance from staff for ADL care including mobility and transfers. The resident stated s/he utilized the rails to sit on the edge of the bed and position himself/herself.

Review of the resident's record showed no documented assessment or evaluation of the side rails.

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/17/23 and 10/18/23. The staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including hypertension.

Observations of the resident, interviews with the resident and staff, and review of the service plan dated 10/05/23 showed the resident had half side rails on each side of the bed, at the head of the bed. The right-side rail was up at all times and the left side rail was down when the resident was out of bed. The resident required extensive assistance from staff for ADL care including mobility and transfers. The resident acknowledged s/he had rails on the bed which s/he used, the resident did not have any other information on the rails to offer.  

Review of the resident's record showed no documented assessment or evaluation of the devices with potentially restraining qualities.   

The need to complete an assessment and the required components for the use of devices with restraining qualities was discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/17/23 and 10/18/23. The staff acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2012 with diagnoses including paraplegia.

Observations of the resident and the resident's room on 10/16/23 through 10/18/23 showed bilateral half-length side rails were installed at the head of the hospital bed and were in the up position. The resident required extensive assistance from staff and received all care in bed. Resident 4 stated s/he used the rails for positioning in bed. The side rails appeared intact and in good repair.

Review of Resident 4's record revealed there was no documented evidence an assessment of the side rails had been completed.

In an interview on 10/17/23, Staff 2 (RCC) confirmed assessment had been completed for Resident 4's side rail use.

The resident's 08/21/23 service plan did not include any information related to the use of side rails, nor any instructions to staff about the correct use of and precautions for the device.  

The lack of an assessment and a service plan with clear instructions for side rail use was discussed with Staff 1 (ED) on 10/17/23. He acknowledged the findings.

OAR 411-054-0060 Restraints and Supportive Devices

1. What actions will be taken to correct the rule violation for each example/resident?

a. Residents #1, #2, #3 and #4 will have a supportive device with restraining properties evaluation completed by the RN.  

b. Following the evaluation, the residents service plans will be updated to ensure inclusion of the supportive device and specific instructions for the care staff.

c. An audit of the community will be conducted to identify all residents who use a supportive device with restraining properties.

d. All community residents who use a supportive device with restraining properties will have a service plan and chart review to ensure evaluations are in place and the service plan includes the device used and instructions for staff.

2. How will the system be corrected so this violation will not happen again?

a. RN will attend the Role of the RN class (current agency RN has attended)

b. All resident rooms will be evaluated, with residents permission,  prior to each service plan update to identify any supportive devices with restraining properties.  

c. Upon admission, the new residents room will be evaluated for supportive devices with restraining properties and all identified devices will evaluated and placed in the service plan.

3. How often will the area needing correction be evaluated?

a. With each admission, quarterly and change of condition service plan update

4. Who will be responsible to see that the corrections are completed/monitored?

a. RN will be responsible to ensure that all supportive devices with restraining properties are identified and service planned.

b. ED will review each service plan for content prior to signing off on the service plan

2. Resident 1 was admitted to the facility in 10/2019 with diagnoses including stroke.

Observations of the resident, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 1's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Bowel and bladder management;

* Transferring in or out of bed or a chair;

* Repositioning in bed or chair;

* Monitoring physical conditions or symptoms;

* Laundry and housekeeping; and

* Pet care.

In an interview on 10/18/23, Staff 2 (RCC) indicated the minutes were inaccurate for the resident but could not say what occurred. Staff 2 stated the resident does have good and bad days so there were occasions s/he needed more assistance with care. She acknowledged the service plan for the resident was not reflective, nor was the ABST data, which potentially created inaccurate staffing data.  

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/17/23 and 10/18/23. The staff acknowledged the findings.

3. Resident 3 was admitted to the facility in 03/2021 with diagnoses including hypertension and chronic pain.

Observations of the resident, interviews with staff, and review of the resident's records noted ABST entries were not reflective of the resident's current care needs.  

A review of Resident 3's ABST, revealed an inaccuracy of minutes assigned in the following areas:

* Transferring in or out of bed or a chair;

* Repositioning in bed or chair;

* Monitoring physical conditions or symptoms;

* Safety checks and fall prevention; and

* Cueing or redirecting due to cognitive impairment or dementia.

In an interview on 10/18/23, Staff 2 (RCC) indicated the minutes were inaccurate for the resident but could not say what occurred. Staff 2 stated the resident does have good and bad days so there were occasions s/he needed more assistance with care and could be a one person assist or a two person assist. She acknowledged the service plan for the resident was not reflective, nor was the ABST data, which potentially created inaccurate staffing data.  

Inaccuracies on resident entries for the ABST tool and potentially inaccurate staffing calculations were discussed with Staff 1 (ED) and Staff 2 (RCC) on 10/17/23 and 10/18/23. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool, the tool was reviewed no less than quarterly, and Acuity Based Staffing Tool (ABST) entries were reflective of the resident's current care needs for 2 of 4 sampled residents reviewed (#s 1 and 3). Findings include, but are not limited to:

1. Review of the current census revealed not all facility residents were entered in to the ABST and multiple residents had not been reviewed or updated quarterly.

Inaccuracies on resident entries for the ABST tool, not including all residents in the tool, and potential inaccurate staffing calculations were discussed with Staff 1 (Executive Director) on 08/21/23. She acknowledged the findings.

OAR 411-054-0037 (1-8) Acuity-Based

Staffing Tool

1. What actions will be taken to correct the rule violation for each example/resident?

a. The ABST will be reviewed by the ED, RN, and RCC for accuracy and updates made according to resident needs.

2. How will the system be corrected so this violation will not happen again?

a. The RCC will receive additional training on completing the ABST.

b. All residents identified as having changes during daily SMART meetings (Monday - Friday) will be reviewed in the ABST at the same time to ensure changes are promptly recorded

c. Each resident who recieves a service plan update will have their ABST entries reviewed and updated prior to completion of the service plan

3. How often will the area needing correction be evaluated?

a. Weekly by the ED and RN during weekly one on one meetings.

4. Who will be responsible to see that the corrections are completed/monitored?

a. The ED and RN during weekly one on one meetings.   

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 12, 13, and 15) completed all required pre-service orientation prior to beginning their job responsibilities, 2 of 2 newly hired direct-care staff (#s 12 and 13) completed dementia training prior to beginning their job responsibilities or providing care to residents, and 1 of 2 sampled staff (#14) who prepared food had a food handler's certificate. Findings include, but are not limited to:

Staff training records were reviewed on 10/18/23 with Staff 4 (Business Office Manager) and identified the following:

a. Training records for Staff 12 (Resident Assistant), hired on 04/12/23, Staff 13 (Resident Assistant), hired on 07/17/23, and Staff 15 (Cook), hired on 08/01/23, lacked documented evidence of Department-approved infectious disease prevention training prior to beginning job duties.

b. Staff 12 and Staff 13 lacked documented evidence of dementia care training prior to beginning job duties including:

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.

c. Staff 14 (Culinary Director), hired 07/01/22, lacked documented evidence of a food handler's certificate.

The need for staff to complete all required pre-service orientation, dementia training and food handler's certification prior to beginning job duties was discussed with Staff 4 and Staff 1 (ED) on 10/18/23. They acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts

and Training: Caregiver Rqmts

1. What actions will be taken to correct the rule violation for each example are as follows:

 a. Staff (#s 12,13, and 15) have all completed all required pre-service orientation for infectious disease training

 b. Staff (#s 12 and 13) have completed dementia training

 c. Staff (#14) has completed a food handler's training and has obtained food handlers certificate.

2. How will the system be corrected so this violation will not happen again are as follows:

 a. Community will use OCP moving forward for all preservice orientation

 b. Community will use OCP moving forwad for all Dementia training

 c. Community will use Oregon approved Food Handlers class with each preservice process for employees

 d. Audit completed of all training records

3. The area needing corrected will be evaluated as follows:

 a. Daily (if applicable) with each new hire during on-boarding training process through completion

 b. A monthly audit will be completed by BOM with ED to check complaince

 c. Daily check in, when working, with BOM from Dept Managers on new hire process and training completion prior to new hires working the floor

4. Who will be responsible to see that corrections are completed/monitored is as follows:

 a. Business Office Manager

 b. ED or designee

Based on record review and interview, it was determined the facility failed to ensure 2 of 2 sampled newly hired direct care staff (#s 12 and 13) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/18/23. The following were identified:

Staff 12 (Resident Assistant) and Staff 13 (Resident Assistant), hired on 04/12/23 and 07/17/23 respectively, did not have documented evidence first aid and abdominal thrust training had been completed within 30 days of hire.

The need to ensure all direct care staff completed first aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) on 10/18/23. He acknowledged the findings.

OAR 411-054-0070 (6)(9) Training within

30 days: Direct Care Staff

1. What actions will be taken to correct the rule violation for each example are as follows:

 a. Staff #12 and #13 have completed First Aid and Abdominal Thrust training

2. How will the system be corrected so this violation will not happen again are as follows:

 a. Audit was completed on training records

 b. OCP for First Aid training will be completed with each new hire within 30 days

3. How often will the area needing corrections be evaluated is as follows:

 a.Daily (if applicable) with each new hire during on-boarding training process through completion

 b. A monthly audit will be completed by BOM with ED to check complaince

 c. Daily check in, when working, with BOM from Dept Managers on new hire process and training completion prior to new hires working the floor

4. Who will be responsible to see that corrections are completed/monitored is as follows:

 a. Business Office Manager

 b. ED or designee

Based on interview and record review, it was determined the facility failed to have documented evidence that Department-approved infectious disease training had been completed annually for 1 of 1 long-term staff (#6) whose training record was reviewed. Findings include, but are not limited to:

Facility training records reviewed on 10/18/23 identified the following:

Training records for Staff 6 (MT), hired 10/27/20, lacked documented evidence of completing annual training on infectious disease outbreak and infection control.

The need to ensure staff completed all required annual in-service training based on anniversary dates of hire was reviewed with Staff 4 (Business Office Manager) and Staff 1 (ED) on 10/18/23. They acknowledged the findings.

OAR 411-054-0070 (5-7) Annual Training

and Other Requirements

1. What actions will be taken to correct the rule violation for each example are as follows:

 a. Staff #6 has completed annual infectious disease outbreak and infection control training

2. How will the system be corrected so this violation will not happen again are as follows:

 a. Audit was completed on training records

 b. Training tracker will be utilized to track annual compliance

3. How often will the area needing corrections be evaluated is as follows:

 a. Monthly audit will be completed by BOM with ED to check complaince

 b. Weekly check in, with BOM from Dept Managers on annual training compliance

4. Who will be responsible to see that corrections are completed/monitored is as follows:

 a. Business Office Manager

 b. ED or designee

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

Fire and life safety records, reviewed between 05/2023 and 10/2023, revealed documentation was lacking in the following areas:

* Location of simulated fire;

* The escape route used;

* Problems encountered;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

Additionally, the records reviewed did not show life safety training was provided on alternating months from the fire drills.

The need to ensure all required components were addressed and documented for each fire drill and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 10/16/23 and 10/17/23. The staff acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life

Safety: Safety

1. What actions will be taken to correct each rule violation for each example are as follows:

 a. Education has been provided to ED and Maintenance Director on Oregon Fire Code related to the following documentation:

* Location of simulated fire;

* The escape route used;

* Problems encountered;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated

 b. Education provided to ED and Maintenance Director on life safety training documentation for staff that is to be provided on alternating months from the fire drills.

2. How will the system be corrected so this violation will not happen again are as follows:

 a. ED will review Fire Drill documentation for accuracy to OAR and OFC for required elements

 b. ED and or Maintenance Director will send/or upload to Tels the Fire Drill form for review from Director of Operation for accuracy

 c. Maintenance program Tels checked for accuracy and scheduling of drills on alternating shifts

3. How often will the area needing correction be evaluated is as follows:

 a. Every other month following drill schedule

4. Who will be responsible to see that the corrections are completed/monitored is as follows:

 a. Maintenance Director

 b. Executive Director

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

On 10/16/23, a double-sided fireplace was observed in the common area near the facility entrance. The fireplace was located where residents gathered and could come into incidental contact with it. The upper portion of the metal fireplace frame measured 187 degrees F when measured with the surveyor's thermometer.

In interviews on 10/17/23 and 10/18/23 Staff 1 (ED) and Staff 3 (Maintenance Director) acknowledged the surface was hot to touch and discussed potential solutions they would be pursuing.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 and Staff 3 on 10/18/23. They acknowledged the findings.

OAR 411-054-0300 (8) Heating and

Ventilation

1. What actions will be taken to correct each rule violation are as follows:

 a. Vendor consulted for checking the heater to ensure there are no damper issues creating increase potential for higher temps.

 b. Screens will be utilized and placed in front of fireplace to assist with preventing incidental touch

2. How will the system be corrected so this violation will not happen again are as follows:

 a. Any repairs have been scheduled/completed per vendor

 b. Community will maintain screen use on Fire Place

 c. Observation/audit will be completed to ensure screens are in use and in good repair

3. How often will the area needing correction be evaluated is as follows:

 a. Daily when working observation audit will be completed to ensure screens are in place and in good repair

4. Who will be responsible to see that the corrections are completed/monitored is as follows:

 a. Maintenance Director, ED, or Designee

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

The building was toured on 10/17/23. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

On 10/18/23, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director). They acknowledged the findings.

OAR 411-054-0300 (11-13) Call System

1. What actions will be taken to correct the rule violation for each example is as follows:

 a. Policy Analyst consulted to apply for exeption due to all 62 resident apartments having patio doors

 b. Door alarms for all other exit doors turned on with current call system

2. How will the system be corrected so this violation will not happen again is as follows:

 a. Audit to ensure door alarms are on and alerting for exit doors (outside of exception) are functioning.

3. How often will the area needing correction be evaluated is as follows:

 a. Weekly audit

4. Who will be responsible to see that the corrections are completed/monitored is as follows:

 a. Maintenance Director or Deisgnee

 b. ED