The findings of the re-licensure survey, conducted 9/22/21 through 9/23/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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 first revisit to the re-licensure survey of 09/23/21, conducted 02/07/22 through 02/08/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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 second re-visit to the re-licensure survey of 09/23/21, conducted 04/21/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and the OARs 411 Division 004 Home and Community Based Services Regulations.

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

During the re-licensure survey, conducted 09/22/21 through 09/23/21, oversight to ensure staff training and adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

1. Executive Director will task appropriate department heads with ensuring that staff training for their department is completed and documented appropriately. The Ed will also provide oversight with the assistance of the DHS to ensure adequate resident care and services are rendered.

2. Executive Director will review training content and completion documentation on a regular basis to ensure that it meets OAR's. All department heads have been given a blank copy of the In-Service Sign-In sheet to document appropriately the training provided, including date, time, location, participants, etc. ED will review citations with each department head and partner together to ensure proper training and oversight is being providedso that regulations are being met.

3. Ongoing on a monthly basis

4. Executive Director

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services rendered in the facility and training of staff. This is a repeat citation. Findings include, but are not limited to:

During the first revisit to the re-licensure survey, conducted 02/07/22 through 02/08/22, oversight to ensure staff training and adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in this report.

1. The Administrator will work with the appropriate department heads to ensure that staff training and adequate resident care and services are being rendered. The community will seek the guidance from an RN Consulting Firm to gain compliance.

2. Community is seeking to retain an RN consulting firm to assist with compliance in resident care and services. A competency based training checklist is being put into place to ensure compliance the training competency.

3. On an ongoing basis.

4. The Administrator or designee along with the appropriate department heads.

Based on observation and interview, it was determined the facility failed to exercise precautions against any condition that could threaten the health, safety, or welfare of residents by not ensuring perimeter walkway surfaces were maintained in good repair. Findings include, but are not limited to:

Observations of the concrete walkways along the perimeter of the building on 09/22/21 showed there were multiple drop offs of 2-4 inches along pathway edges, which created potential hazards for residents.  

The need to ensure the pathways did not have potential safety hazards was discussed with Staff 3 (Director of Environmental Services) on 09/22/21. He acknowledged the findings.

1. Dirt, decorative mulch, gravel or a combination will be added along pathways in order to bring the drop offs along the sidewalks and planters up to the same elevation.

2. The Director of Environmental Services will monitor the areas on a weekly basis to ensure the pathways remain safe and hazard free from drop offs. Dirt, decorative mulch and/or gravel will be added as needed in order to maintain the safetfy of the pathways.

3. Weekly

4. DES as well as ED

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

During a tour of the kitchen with Staff 12 (Executive Chef/Director of Dietary Services) on 09/22/21 at approximately 10:00 am, the following was observed:

* The salad bar refrigerator and the walk in refrigerator lacked thermometers;

* Dented large can of tomatoes on the canned goods rack in the dry storage room;

* Front of range/grill in disrepair with grease, spills, and splatters;

* Spills and splatters on legs of rolling carts used for bussing tables;

* Dishwasher racks stored directly on the floor;

* Counter and cabinets of beverage service station in dining room chipped in multiple areas exposing non-cleanable surface; and

* Juice machine with splatters and drips.

The areas needing cleaning and repair were discussed with Staff 4 (Executive Chef/Director of Dietary Services) on 09/22/21. He acknowledged the findings.

On 9/22/21 thermometers were purchased and placed in each refrigerator and freezer. Daily temp logs will be maintained by the Executive Chef or Sous Chef on a daily basis. A box for dented cans was labeled and placed in the kitchen. Executive Chef and Sous Chef will be responsibe for monitoring can rack on a weekly basis for dented/damaged cans. On 10/8/21, grill was disassembled and deep cleaned and put back together. A check off/sign off sheet for a cleaning routine will be implemented and overseen by EC. Rolling carts were deep cleaned and sanitized on 9/22/21. The Dining Room Supervisor will be tasked to provide the oversight of cleanliness/sanitization on a daily basis. Shelves were purchased on 9/22/21 for the dish racks to sit on top of. EC will ensure that dish racks remain on the shelves.DES will contact contractor to replace/repair broken countertop and cabinets. EC will follow up on completion status with DES. Expected to be complete by 11/20/21. Juice machine was cleaned on 9/22/21 and will be montored by the Dining Room Supervisor and cleaned on a daily basis

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

During a tour of the kitchen with Staff 4 (Executive Chef/Director of Dietary Services) on 02/07/22 at approximately 10:00 am, the following was observed:

* Black substance was on the stainless steel back splash against the wall;

* White crusty substance and food crumbs were on the dish washer;

* Leaking pipes dripping black water underneath the dishwashing sink;

* Food and dirt debris under the triple wash sink; and

* Flooring throughout the kitchen were observed to have food and dirt debris.

A tour of the kitchen was conducted with Staff 13 (Executive Director) and Staff 4 (Executive Chef/Director of Dietary Services) on 02/07/22. They acknowledged the findings.

1. The black substance (mold on caulking) was removed and replaced. Leaking pipes were tightened and resealed. Kitchen staff performed a deep cleaning on the kitchen overnight.

2. A new Director of Dining Services has been hired. Along with the ED or designee, the DDS will provide oversight of the kitchen for cleanliness on a daily basis.

3. The cleanliness of the kitchen will be evaluated on a daily basis.

4. The Director of Dining Services will be responsible to ensure that the corrections are completed in its entirety and monitored on a daily basis with oversight being conducted by the Administrator or designee

Based on observation, interview, and record review, it was determined the facility failed to ensure an initial new move-in evaluation included information on all required elements for 1 of 1 sampled resident (#1) and failed to ensure quarterly evaluations were reflective of the residents' current status for 1 of 2 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2017 with diagnoses including a compression fracture. During the acuity interview on 09/22/21, Resident 3 was identified as having fallen and fractured his/her pelvis and had been recently admitted to hospice.

Resident 3's record revealed s/he had fallen on 08/19/21 and was sent to the Emergency Department. Resident 3 returned to the facility with a diagnoses of an urinary tract infection. Staff monitored Resident 3 each shift and noted continued pain. On 08/25/21 Resident 3 was sent to the Emergency Department for uncontrolled pain and diagnosed with a fractured pelvis.

Resident 3 returned to the facility on 09/2/21, had been admitted to hospice services, had an external catheter, required two staff to assist with transfers, and assistance with all ADLs.

In an interview with Witness 1 (Resident 3 family member), s/he reported Resident 3's laundry was done by family.

An evaluation of Resident 3, completed on 09/17/21, was not reflective of the resident's current status in the following areas:

* Pharmaceutical and non-pharmaceutical interventions for pain, including expression of pain or discomfort;

* Toileting, bowel and bladder management including assistance with incontinence and information or direction for the external catheter;

* Mobility, ambulation, and transfers including the assistance of two staff,

* Laundry; and

* Nursing needs.

The need to ensure quarterly evaluations were accurate and included documented changes of condition was discussed with Staff 1 (RN Director of Health Services) on 09/22/21. She acknowledged the findings.

2. Resident  1 was admitted to the facility on 08/18/21 with a diagnosis of a neck fracture and depression.

Resident 1's initial evaluation, dated 08/18/21, lacked the following elements:

* Customary eating routines;

* List of medications and PRN use;

* Visit to healthcare practitioners, ER or hospital;

* History of mental health treatment;

* Effective non-drug interventions for mental health;

* Nutrition habits and fluid preferences;

* Fall risk or history; and

* Recent losses.

The need to ensure the new move-in evaluation contained all required elements was discussed with Staff 1 (RN Director of Health Services)  on 09/22/21. She acknowledged the findings.

All required elements for initial move-in on resident 1 as well as any future move-in's will be completed thoroughly by the DHS and updated/modified as needed 30 days after the resident moves in. Initial move in assessments will contain the needs and preferences of that specific resident . Moving forward, quarterly assessments (or more frequent as needed) will be accurate and thorough and incude any documented changes in condition along with the service plan to accommodate for the changes. DHS, with Executive Director oversight, will be responsible for ensuring documentation is complete, up to date and accurate. Initial move in evaluation for resident 1 and quarterly assessment for resident 3 will be completed by 10/29/21. DHS will utilize the "Service Plan Due" tab in ALAdvantage to track quarterly assessment due dates as they come up. The DHS, along with the HSA and ED will partner together to ensure completion of all initial move-in evaluations prior to move in as well as quarterly evaluations on an on going basis.

2. Resident 3 was admitted to the facility in 03/2017 with diagnoses including a compression fracture. The resident's 09/17/21 service plan was reviewed and found to not be reflective of the resident's current status and needs, and lacking clear direction for staff in the following areas:

* Transfer and mobility assistance;

* Toileting and incontinence assistance;

* Pain;

* Laundry;

* Oxygen use; and

* Pet care.

The need to ensure service plans were reflective of the resident's needs and provided clear direction to staff was discussed with Staff 1 (RN Director of Health Services) on 09/22/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear direction to staff for 2 of 2 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2021 with a diagnosis of neck fracture and falls.

Progress notes dated 08/18/21 through 09/21/21 were reviewed and identified the following:

Resident 1 experienced three non-injury falls and two falls with injury. The service plan for Resident 1 was not updated with interventions to reduce falls, transfer assistance needed, or the use of an abdominal binder for transfer safety.

The need to ensure service plans were reflective of residents' current status and provided clear direction to staff was discussed with Staff 1 (RN Director of Health Services) on 09/22/21. She acknowledged the findings.

The DHS with assistance from the HSA will ensure service plans are reflective of the residents current status, needs and preferences at the time of move in and will be initiated immediately upon move in for each new resident. Updates to the service plan will coincide with the quarterly assessment or upon a change of condition and will thoroughly reflect the residents current status, needs and preferences at that time and will provide clear direction for the staff. Service plans for resident 1 and 3 will be accurately updated by 10/29/21. On an ongoing basis, the DHS and HSA will monitor the "Service Plan Due" tab in ALAdvantage and ensure service plans are updated. With oversight from the ED, the DHS and HSA will be responsible for ensuring that service plans are complete, accurate based on the most recent assessment and provide clear communication to the staff  

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

1. Resident 4 was admitted to the facility in 11/2021 with a diagnosis of congestive heart failure, sleep apnea and edema. S/he had become bedbound prior to 12/25/21 due to severe pain.

An interview with Staff 4 (Health Services Assistant) on 02/07/22 revealed Resident 4 received bed baths from hospice once a week, required an air mattress, was a two-person hoyer transfer, needed repositioning three times per shift and required his/her heels to be elevated while in bed. The service plan was not updated to reflect his/her current care needs regarding severe pain, bed baths from hospice once a week, use of an air mattress, two-person transfer with a hoyer, need for repositioning three times per shift and heels to be elevated in bed.

During an observation of Resident 4 on 02/07/22, s/he was observed to be on an air mattress and his/her heels were resting on the mattress rather than being elevated.

The need to ensure service plans were reflective of residents' current status and provided clear direction to staff was discussed with Staff 13 (Executive Director) on 02/08/22. She acknowledged the findings.

1. Resident care plans will be updated to reflect the most current needs of the resident. Staff to review updated care plans and will receive training by compliance date. Resident 4's care plan has been updated to reflect the need to have heels elevated.

2. Care plans will be updated quarterly and/or upon a change of condition to reflect the residetns current needs. Care plan due dates will be entered into ALAdvantage as a reminder.

3. Care plans will be updated quarterly or as needed upon a change of condition

4. Asssited Living Director and Health Services Assistant will be responsible for completion and monitoring along with oversight from Administrator or designee

Based on interview and record review, it was determined the facility failed to evaluate and monitor changes of conditions, refer any significant changes of condition to the RN, determine and document actions or interventions, and communicate those to staff, for 2 of 2 sampled residents (#s 1 and 3) whose records were reviewed. Findings include, but are not limited to:

1. Review of Resident 1's progress notes dated 08/18/21 through 09/21/21 revealed the following changes of condition were not monitored until resolved:  

* Multiple falls;

* Medication change; and

* New move-in.

The need to ensure the facility evaluated and monitored changes of condition, determined and documented actions or interventions and communicated those to staff was discussed with Staff 1(RN Director of Health Services) on 09/22/21. She acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2017 with diagnoses including a compression fracture. During the acuity interview on 09/22/21, Resident 3 was identified as having fallen and fractured his/her pelvis and had been recently admitted to hospice.

a. On 08/25/21 Resident 3 was sent to the ER for "uncontrollable pain" and diagnoses with a pelvic fracture. S/he returned to the facility on 09/2/21 with an external catheter and had been admitted to hospice for end of life services.  

There was no evaluation of Resident 3's significant changes in condition and no evidence of a referral to the facility RN.

b. Resident 3's progress notes and hospice communication indicated:

* 08/20/21 - "Resident had an injury fall last night and was sent to the ER via ambulance. [S/he] did come back later in the night and they said [s/he] has a hematoma to the right of [his/her] coccyx.";

* 09/5/21 - "...[Patient] mouth is red, there are no flat fixed white patches."; and

* 09/9/21 - "...skin around anus with yeast looking pimples..."

There was no evidence the short term changes had been evaluated, interventions determined and communicated to staff, and monitored.

The need to ensure changes in condition were evaluated, referred to the RN if significant, and monitored weekly until resolved, was reviewed with Staff 1 (RN Director of Health Services) on 09/22/21. No further information was provided.

1. Resident 1 A Morse Fall scale will be completed to help identify any potential needs or concerns. A complete and thorough move in process will be completed.Moving forward, progress notes on medication changes will be documented.

Resident 3: A temporary care plan will be put in place and changes in condition will be evaluated and communicated to the RN until resolved

 2.A complete review of all care plans will be conducted to ensure the residents current conditions are captured. Training with med techs will be completed on how to identify, monitor and communicate changes of condition until resolution.

3. Daily review of temporary care plans, alert charting and 24 hour log will be completed.

4. Administrator, Health Service Assistant, and nurse are responsible for correction and monitoring.

Based on interview and record review, it was determined the facility failed to document and communicate to staff what actions or interventions were needed following a short term change of condition, monitor changes of condition and refer any significant changes of condition to the RN, for 2 of 2 sampled residents (#s 4 and 5) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 11/2021. Review of the resident's progress notes, dated 11/15/21 through 01/06/22 revealed the facility failed to document and communicate to staff what actions and interventions were needed for the resident and the following changes of condition were not monitored at least weekly until resolved:  

* Placement of indwelling catheter;

* UTI and effectiveness of antibiotics;

* Becoming bed-bound;

* Medication change; and

* New move-in.

Placement of the indwelling catheter and becoming bedbound represented significant changes of condition for which there was no evidence the RN was notified.

2. Resident 5 was admitted to the facility in 02/2014. Review of the resident's progress notes, dated 10/01/21 through 01/29/22 revealed the following changes of condition were not monitored until resolved:

* Left foot fracture;

* Mobility using protective boot;

* Medication change;

* Left shoulder fracture;

* ADL needs using immobility sling; and

* Pain resulting from the two fractures.

The need to ensure the facility documented and communicated to staff what actions or interventions were needed following a short term change of condition, monitored changes of condition and referred any significant changes of condition to the RN was discussed with Staff 13 (Executive Director) and Staff 16 (Director of Assisted Living) on 02/08/22. They acknowledged the findings.

1. Resident 4: Contracted RN will complete the proper documentation and review progress notes.

Resident 5: A temporary care plan was put into place and changes in condition will be evaluated and communicated to the RN until resolved.

2. A complete review of all care plans will be conducted to ensure the residents current conditions are captured.

Staff will receive training on change of condition reporting by the compliance date.  Staff will have received training on the use of the 24 hour book by the compliance date. The staff will be trained on the use of TSPs and interventions for change of condition by the compliance date.  Staff will receive training on alert charting by the compliance date.

3. Daily review of temporary care plans, alert charting and 24 hour log will be completed.

4. RN, Assisted Living Director, Health Services  Assistant or designee are responsible for correction and monitoring.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes in condition, including findings, resident status, and interventions made as a result of the assessment, for 1 of 2 sampled residents (#3) who experienced significant changes in condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2017 with diagnoses including compression fracture.

Resident 3's record revealed s/he had fallen on 08/19/21 and was sent to the Emergency Department. Resident 3 returned to the facility with a diagnoses of an urinary tract infection. Staff monitored Resident 3 each shift and noted continued pain. On 08/25/21 Resident 3 was sent to the Emergency Department for uncontrolled pain and diagnosed with a fractured pelvis.

Resident 3 returned to the facility on 09/2/21, had been admitted to hospice services, had an external catheter, required two staff to assist with transfers and assistance with all ADLs.

There was no evidence of an RN assessment of Resident 3's significant changes in conditions.

On 09/17/21, 15 days after Resident 3 returned to the facility on hospice with a fractured pelvis, Staff 1 (RN Director of Health Service) documented a Quarterly Assessment had been completed. There was no evidence the assessment included findings, resident status and interventions made as a result of the assessment.

The need to ensure significant changes in condition were assessed timely and included findings, resident status and interventions made as a result of the assessment, was reviewed with Staff 1 on 09/22/21. She acknowledged the findings.  

1. Resident 1's assessment will be updated to reflect changes of condition, current status and appropriate interventions.

2. Any time there is a significant change in condition, the resident will be thoroughly assessed in a timely manner. The assessment will include findings, resident status and interventions.

3. Quarterly or upon a change of condition.

4. Nurse, HSA, ED

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes in condition, including findings, resident status, and interventions made as a result of the assessment, for 1 of 2 sampled residents (#4) who experienced significant changes in condition. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 11/2021 with diagnoses of congestive heart failure and chronic pain.

a. Resident 4's record revealed an external catheter was placed on 11/18/21 to help with urinary urgency.

b. An interview with Staff 4 (Health Services Assistant) on 02/07/22 revealed Resident 4 had been bedbound prior to 12/25/21 due to chronic pain.

Placement of the catheter and becoming fully bedbound represented significant changes of condition for Resident 4. There was no documented evidence of an RN assessment of Resident 4's significant changes in condition.

The need to ensure significant changes in condition were assessed timely and included findings, resident status and interventions made as a result of the assessment, was reviewed with Staff 13 (Executive Director) and Staff 16 (Director of Assisted Living) on 02/08/22. They acknowledged the findings.

1. An RN assessment will be completed on resident 4 to document the significant changes of condition including the placement of an external catheter and the resident becoming bedbound due to chronic pain.

2. The RN will be notified of significant changes in condition and will complete an assessment in a timely manner and document the findings, resident status and interventions made as a result of the assessment. Clinical staff will receive training on the criteria for significant change in condition and policy.

3. Daily review of TCP, alert charting and 24 hour logs for significant changes of condition.

4. Director of Assisted Living, contracted RN, ED or designee

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 1 sampled resident (#2) who received services from an outside provider. Findings include, but are not limited to:

Resident 2's clinical record was reviewed during the survey.

a. On 08/18/21 PT documented resident had to wear TED hose and an abdominal binder when standing. There was no documented evidence staff were informed of the new interventions and the service plan was not updated.

b. Resident 2 had an order for Coumadin 4.5 mg once a day starting on 08/18/21. Review of Resident 2's clinical records did not indicate s/he was having his/her INR tested, which was used to monitor individuals who were being treated with blood thinning medication, such as Coumadin. There was no documented evidence the facility had policies or procedures for residents on Coumadin. In an interview with Staff 1 (RN Director of Health Services) on 09/23/21, she acknowledged the facility should have scheduled routine labs to check Resident 2's INR to adjust Coumadin orders.

The surveyor asked Staff 1 to set up an appointment for Resident 2 to have his/her INR checked. Staff 1 confirmed an appointment before the surveyor exited the facility.

The need to ensure care with outside providers was coordinated and recommendations communicated to staff was discussed with Staff 1 on 09/23/21. She acknowledged the findings.

1.a. Resident 2's care plan will be updated to reflect any PT documentation, including the need to wear TED hose and an abdominal binder when standing.

1.b. An appointment was made for Resident 2 to have their INR checked

2. Any documented changes made by PT or another outside provider will be reflected in the residents care plan. Staff will be informed of the updated care plan, sign off on the care plan acknowledging they understand the changes and will immediately implement the changes. Residents will be asissted with scheduling routine labs/appointments.

3. Any time new documentation is provided by an outside provider an on-going basis or appointments are needed to be scheduled with an outisde provider.

4. DHS, HSA

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 1 sampled resident (#4) who received hospice services. This is a repeat citation. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 11/2021. The resident's clinical record was reviewed during the survey.

a. On 01/26/22 a hospice LPN documented the use of foam ear protectors with the resident's oxygen tubing to prevent sores behind the ears. There was no documented evidence staff were informed of the new interventions and the service plan was not updated.

b. On 02/02/22, a hospice RN documented the use of 50/50 Calazinc cream and skin repair cream to buttocks with each brief change. There was no documented evidence staff were informed of the new interventions and the service plan was not updated.

The need to ensure care with outside providers was coordinated and recommendations communicated to staff was discussed with Staff 13 (Executive Director) and Staff 16 (Director of Assisted Living) on 02/08/22. They acknowledged the findings.

1. All documentation from outside providers will be reviewed on a daily basis by the Assisted Living Director/Health Services Assistant or designee to ensure that care is coordinated and recommendations/new orders are communicated with staff

2. Moving forward, all documentation from outside providers will be reviewed by the Assisted Living Director/Health Services Director to ensure care is coordinated and that recommendations, interventions and new orders are communicated with the staff.

3. Any time a resident receives care from an outside provider.

4. Assisted Living Director, Health Services Assistant, RN or designee.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:

Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

C290: Coordination of care with outside providers for Coumadin.

The unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 (RN Director of Health Services) on 09/23/21. She acknowledged the findings.

1. Residents will be assisted with the scheduling of appointments with outside providers including providers for Coumadin INR checks.

2, DHS will review service plans and MAR's and identify any resident needing oversight from an outside provider. If not already complete, DHS or HAS will reach out to outside provider to initiate coordination of care.

3. Monthly and with any medication/treatment changes or new medication/treatment orders.

4. DHS and HSA

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 1 of 3 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to:

Resident 3's current physician orders and 09/01/21 - 09/22/21 MARs were reviewed.

Resident 3 had physician's orders for Hydrochlorothiazide 25 mg and Losartan Potassium 25 to be given daily for high blood pressure. The medications were to be held if the blood pressure was less than 100/60.

There was no evidence Residents 3's blood pressure was monitored to determine if the medications should be held.

The need to ensure medication and treatment orders were carried out as prescribed was discussed with Staff 1 (RN Director of Health Services) and Staff 4 (Health Services Assistant) on 09/23/21. They acknowledged the findings.

1. Resident 3's order for Hydrochlorothiazide and Losartan was reviewed with community RN who implemented BP checks with am meds to assess for need of Hydrochlorothiazide and Losartan based off BP reading. Communication fax was sent to residents PCP for further parameters.

2. Quarterly pharmacy audit is completed by Omnicare to provide community with recommendations for any concerns or indications for each resident. Quarterly medication orders are sent to each residents PCP for review and any changes are updated to reflect in residents current EMAR.

3. Quarterly and with any med changes or new medications prescribed to resident.

4. Health Service Assistant, Nurse, Administrator.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 1 of 1 sampled resident (#3) who was prescribed a PRN medication to address behaviors. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2017 and was noted to have anxiety.

Review of Resident 3's 09/01/21 through 09/22/21 MARs and hospice orders showed the following:

* Lorazepam (anti-anxiety medication) 0.5 mg every two hours as needed for anxiety or agitation.  

Resident 3 was administered the PRN psychoactive medication on 09/04/21.

The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety and agitation. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and agitation, and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (RN Director of Health Services) 09/22/21. She acknowledged the findings.

1. Administration of PRN psychoactive medications will include written resident-specific parameters and documentation by staff that include how the resident expressed the need for the medication and what non-drug interventions were attempted prior to the administration of the medication.

2. The Nurse will review all PRN orders for psychoactive medications and ensure that resident-specific parameters and non-drug interventions are included on the MAR. Med Techs will be in-serviced on the need to attempt and document non-drug interventions prior to the administration of a psychoactive medication.

3. Monthly and with any new or updated PRN order for psychoactive medications.

4. Nurse

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

During the acuity interview on 09/22/21, the facility was home to 38 residents. Four residents were identified to require the assistance of two staff for transfer assistance. An additional two residents were identified with high ADL care needs.   

In addition to caregiving and medication duties, staff were observed to provide:

* Laundry service; and

* Delivery of meals to resident rooms.

Resident 2 was identified to require "...extra time...generally requires 60-90 minutes for [his/her] morning routine..."

In interviews with staff, they indicated Resident 2 required the assistance of two staff for transfers.

Resident 2 reported staff would come and turn off the call light and state they would be back to provide assistance and then not return.

Review of the call light response times from 08/01/21 to 09/22/21 for Resident 2 revealed 22 times the response was 20 minutes or greater

In individual resident interviews it was reported call light response times could be up to an hour.

In an interview with a family member, they reported extended times to respond to call lights.

Review of the schedule for 09/20/21 through 09/23/21 revealed the facility had three staff scheduled for the swing shift, one MT and two CGs, and two to three staff, one MT and one to two CGs, scheduled for the overnight shift. MT's were reported to not generally help with caregiving due to being busy with medication pass duties.

The failure to adjust staffing levels, based on caregiving staff duties that included laundry services, meal delivery, and meeting the needs of multiple resident's requiring the assistance of two staff, was discussed with Staff 1 (RN Director of Health Services) on 09/23/21. She acknowledged the findings and reported the facility was attempting to hire more staff.

1. Resident care levels/needs and services will be reviewed along with current staffing schedules to determine appropriate staffing levels.

2. Staffing will be based off of current care levels/needs and services and to accommodate scheduled and unscheduled needs of residents, a quicker response time to call lights and staff duties beyond direct resident care.

3. Ongoing. Also to be reviewed after a significant change in a care plan and upon a new resident move in

4. HSD, ED

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

During a review of staff training records on 09/22/21, Staff 1 (RN Director of Health Services) was unable to provide documented evidence the sampled newly-hired staff had demonstrated competency in any duties they were assigned or completed any pre-service training. Staff 1 further confirmed the facility did not have a process for evaluating competency and currently, no staff had verified competency in their assigned duties.

The need to have a training program that included methods to determine competency of direct care staff through evaluation, observation, or written testing was discussed with Staff 1 on 09/22/21. She acknowledged the findings.

Refer to C 370, C 372, and C 374.

1. The community will implement a training program for newly hired direct care staff that has a method to determine competency of the direct care staff and will maintain this documentation.

2. Upon hire of new direct care staff and after training completion, a competency determination will be made and documented through evaluation, observation or written testing. A binder will be implemented to house all training documentation

3. Upon new hire and then on an annual basis for competency. Maintaining written documentation of all trainings - on an ongoing basis

4. DHS, HSA and ED

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 9 and 10) completed all required pre-service orientation and pre-service dementia training before providing care to residents. Findings include, but are not limited to:

Review of staff training documents on 09/22/21 revealed:

Staff 5 (MT) hired on 06/22/21, Staff 9 (CG) hired on 08/18/21 and Staff 10 (MT) hired on 08/13/21 lacked documentation for any pre-service orientation and pre-service dementia training before providing care to residents.    

The need to ensure pre-service orientation and dementia training was completed before providing care to residents was discussed with Staff 1 (RN Director of Health Services) on 09/22/21. She acknowledged the findings.

1. The community will re-evaluate the implementation of the pre-service orientation and dementia training program and documentation procedures to ensure compliance. All current staff out of compliance will complete the pre-service orientation and dementia training.

2. All newly hired staff will be assigned the pre-service orientation and dementia training at the time of their onboarding. The new staff member will not be scheduled to work providing direct care to residents until the required orientation and training is complete and properly documented.

3. At the time of hire and again prior to scheduling the new staff member to perform direct care.

4. Business Office Manager, DHS

Based on interview and record review, it was determined the facility failed to ensure 3 of  3 newly hired staff (#s 5, 9, and 10) demonstrated competence in all job duties within 30 days of hire. Findings include, but are not limited to:

Review of staff training records on 09/22/21 revealed:

Staff 5 (MT) hired 06/22/21, Staff 9 (CG) hired 08/18/21, and Staff 10 (MT) hired 08/13/21, lacked documentation for any return demonstration of:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* First aid and abdominal thrust;

* General food safety, serving and sanitation; and

* Medication Administration.

Staff 1 (RN Director of Health Services) was informed Staff 5 and 10 needed to demonstrate competence in medication administration prior to completing another medication pass. Staff 1 provided documentation that Staff 5 and 10 demonstrated competence in medication pass on 09/23/21.

The need to ensure newly hired staff demonstrate competencies in all job duties and first aid and abdominal thrust within 30 days of hire was discussed with Staff 1 on 09/22/21. She acknowledged the findings.

1. All department heads have been given a blank copy of the In-Service Sign-In sheet to document appropriately any training provided, including training topic,date, time, location, participants, etc.

2. Individual employee training files will be audited and employees will immediately be assigned any missing training components and evaluated for competency, so that they are in compliance with OAR 411-054-0070, including First Aid/CPR and Food Handler's.

3. Upon any new hire, the DHS, BOM and ED will work together to ensure that all required training within 30 days is completed, a competency evaluation completed and documented appropriately. Ongoing training will also be conducted and documented appropriately.

4. The DHS and ED will partner on an ongoing basis to ensure that all training requirements for the care department are met and documented  

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 14 and 15) demonstrated competence in all job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of staff training records on 02/07/22 revealed:

Staff 14 (CG) hired 10/21/21, and Staff 15 (CG) hired 10/20/21, lacked documentation for any return demonstration of the following required training topics:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and

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

The need to ensure newly hired staff demonstrate competencies in all job duties within 30 days of hire was discussed with Staff 13 (Executive Director) on 02/07/22. She acknowledged the findings.

1. Assisted Living Director will put into place a comeptency based training reporting system to ensure all new hires can demonstrate competency in all job duties within 30 days of hire

2. A competency based checklist will be used and each team member will demonstrate competency to the Assisted Living Director or Health Services Assistant within 30 days of hire.

3. With every new hire, within 30 days of hire.

4. Assisted Living Director and Health Services Assistant.  

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 long term staff (#s 6, 7, 8 and 11) had documented evidence of completing 12 hours of in-service training, six of which related to dementia care and six related to provisions of care in CBC. Findings include, but are not limited to:

Review of staff training documents on 09/22/21 revealed:

Staff 6 (MT), hired 05/22/20, Staff 7 (CG) hired 09/13/18, Staff 8 (CG) hired 10/22/15, and Staff 11 (MT) hired 07/18/17, lacked documented evidence of 12 hours of annual in-service training, six hours related to dementia care and six hours related to provision of care in CBC.

Staff 1 (RN Director of Health Services) revealed she did not have any documentation of staff training.

The need to ensure all long-term staff receive 12 hours of annual in-service training, six hours related to dementia care and six hours related to provisions of care in CBC setting, was discussed with Staff 1 (RN Director of Health Services) on 09/22/21. She acknowledged the findings.

1. Individual employee training files will be audited and employees will immediately be assigned any missing training components, including dementia training, based on their anniversary date of hire, so that they are in compliance with OAR 411-054-0070.

2. Ongoing training, including dementia training, along with competency assessments will also be conducted and documented appropriately.

3. The DHS and ED will partner on an ongoing basis to ensure that all training requirements for the care department are met and documented

4. DHS, HAS, ED

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and to conduct fire life safety training on alternating months. Findings include, but are not limited to:

Fire and life safety records for 03/2021- 09/2021 were reviewed with Staff 3 (Director of Environmental Services) and lacked the following components:

* Evacuation time period needed;

* Escape route used;

* Number of occupants evacuated; and

* There was no documented evidence fire and life safety training was conducted on alternating months.

The need to ensure the facility was in compliance with all required fire drill components and fire and life safety instruction was discussed with Staff 3 on 09/22/21. He acknowledged the findings.

1. The DES will ensure that all fire drills are conducted on an every other month basis and according to the Oregon Fire Code and that on alternate months, fire and life safety trainings are completed and are documented. Documentation to include: evacuation time period needed, escape route used and number of occupants evacuated.

2. A new Safety binder will be created for the documentation of life safety trainings, including a schedule of the training topics. All fire drills will be properly documented and include all components, including the evacuation time period, number of occupants evacuated, date and time as well as location of simulated fire. All life safety drills/trainings will have an attendance sheet. The TELS system will send out reminders for the monthly drills/trainings to be conducted.

3. On a monthly basis, the DES along with the ED will work together to ensure that the trainings are being implemented and documented according to the regulations.

4. The DES as well as the ED will ensure that the corrections are completed and monitored on a regular basis

Based on interview and record review, it was determined the facility failed to conduct all fire drills according to the Oregon Fire Code (OFC) and document all required components of fire drills. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records from 10/01/21 through 01/31/22 were reviewed with Staff 3 (Director of Environmental Services) and lacked documentation of the following components:

* Escape route used; and

* Number of occupants evacuated.

In an interview with Staff 3 and Staff 13 (Executive Director) on 02/07/22, they acknowledged the facility was not relocating or evacuating residents during fire drills.

The need to ensure the facility was in compliance with all required fire drill components was discussed with Staff 3 and Staff 13 on 02/07/22. They acknowledged the findings.

1. The DES will conduct a fire drill by 3/15/22 and will ensure proper documentation and moving forward will ensure that all fire drills conducted will include proper documentation consisting of escape routes used and number of occupants evacuated.

2. A fire drill form will be used that includes a specific area to document the escape route used as well as the number of occupants evacuated

3. Each and every time a fire drill is conducted

4. Director of Environmental Services with oversight from the Administrator or designee

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 C 150, C 240, C 260, C 270, C 280, C 290, C 355, C 372 and C 420.

1. The Administrator along with the RN and appropriate department heads will provide the oversight to ensure compliance of C150 Facility Administration, C240 Resident Services Meals and Food Sanitation Rule, C260 Service Plan, C270 Change of Condition and Monitoring, C280 Resident Health Services, C290 On and Off Site Health Services, C372 Training within 30 Days for Direct Care Staff, C420 Fire and Life Safety.

2. The Administrator or designee along with the appropriate department heads and community staff will work together to ensure full compliance with OAR's

3. On a regular, ongoing basis.

4. Department heads, community staff and the Admisinstrator or designee

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes to alert staff when residents exited the facility. Findings include, but are not limited to:

On 09/22/21, it was observed exit doors did not have an alarm or other system to alert staff when residents exited the facility.

In an interview on 09/23/21, Staff 3 (Director of Environmental Services) confirmed the doors that lead outside did not have an alarm that alerted staff when a resident went outdoors.

The need to ensure all exit doors had an alarm or other acceptable system to alert staff when residents exited the facility was discussed with Staff 3 on 09/23/21. He acknowledged the findings.

1. On 10/8/21 all exit doors were fitted with door alarms that provide activity alerts 24 hours a day.

2. The alarms are tied to the nurse call system and transmit an alarm to the front desk as well as to the 2 way radios carried by the RA's. Each door has a reset button to clear the alarm once triggered. All RA's and front desk staff will be in-serviced on how to respond to the door alarms.

3. A weekly testing by the DES will be conducted and documented on the door alarms to ensure functionalty. 4. The DES and ED will work together to ensure the continued operation of the door alarms.