The findings of the re-licensure survey conducted 04/16/24 through 04/19/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 04/16/24, conducted 10/01/24 through 10/03/24, 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 OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

A situation was identified which represented an immediate threat to residents' health and safety and required an immediate plan of correction in the following area:

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

The facility put an Immediate Plan of Correction in place during the survey.

The findings of the second revisit to the relicensure survey of 04/19/24, conducted 01/23/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure incidents were immediately investigated to rule out abuse and suspected abuse, and reported to the local SPD (Seniors and People with Disabilities) office when abuse could not be ruled out for 1 of 1 sampled resident (# 3) who was reviewed for incidents. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.    

Observations of the resident, and interviews with the resident's family and staff were conducted. Resident 3's clinical records and incident investigations were reviewed. The following was identified:

* Resident 3 had an unwitnessed fall with injury on 11/08/23, and was unable to report what happened. There was no documented evidence the facility immediately conducted an investigation that ruled out abuse or reported the incident to the local SPD office, and the investigation lacked the following components; Individuals present, response of staff at the time of the event, follow-up action, and administrator's review.

* On 03/06/24, the resident left the facility to go to the grocery store that was across the street. Resident 3 became disoriented and was not able to find his/her way back to the facility without a third party intervention, which constituted an elopement.

There was no documented evidence the facility reported the elopement to the local SPD office. The facilities investigation lacked the following components; Individuals present, response of staff at the time of the event, follow-up action, and administrator's review.

On 04/17/24, the surveyor requested Staff 1 (Executive Director) report the incident to the SPD office. Staff 1 provided verification of the report on 04/18/24.

The need to ensure all incidents of abuse or suspected abuse were immediately reported, and investigations included documentation of all required elements, was discussed with Staff 1, Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

OAR 411-054-0028 (1-3)

Reporting and Investigating Abuse-Other Action

1. Actions taken to correct the rule violation is as follows:

Resident #3 elopement incident was reported to the local SPD office on 4/17/24 after the request from the surveyor.

2.To ensure the system will be corrected so this

violation will not happen again:

    a. All staff will be provided training on the following

topics: Incident report requirements, investigating

incident reports, how to appropriately rule out abuse and neglect, implementing new interventions via TSPs, ensuring previous interventions  and applicable service planning care were being followed to showcase rule out abuse and  neglect

secondary to as evidenced by when to report and when to local APS.

    b. The system will be corrected so the violation will not happen again by ensuring all incidents are investigated timely. If abuse or neglect can not be ruled out, or for injuries of unknown cause, community will follow Abuse reporting requirement to APS. Incident reports are reviewed with daily stand up meetings. The community will include incident reporting and investigating abuse and neglect as part of the continuous quality improvement plan. Community will verify the correct process for self reporting to APS has taken place for all reportable incidents.

3. This area will be reviewed on a daily basis with incident review in stand up, nad on a quarterly basis.

4. The Facility Administrator or designee will be responsible for ensuring the system is corrected and monitored.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation for 1 of 1 newly admitted resident (# 4) and failed to ensure 1 of 2 sampled residents (# 1) evaluations were completed quarterly with data that was relevant to the needs and current condition of the resident. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 02/2024 with diagnoses including cortical basal syndrome (asymmetric involuntary movements).

Resident 4's move-in evaluation, dated 2/13/24, was reviewed during survey.  The following required elements were not addressed:

*Interests, hobbies, social, leisure activities;

*Mental Health issues including: effective non-drug interventions;

*Recent losses; and

*Alcohol use.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator), and Staff 11 (Medication Care Manager) on 04/18/24. No additional information was provided.

2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, anemia, cardiac disorder, and dementia.

Review of the resident's quarterly evaluations dated 11/28/23 and 03/19/24 revealed the most recent evaluation was not performed quarterly and did not address or update all required elements, including the following:

* Required transfer enabling devices;

* Dietary needs and assistance; and

* Routine medication administration.

The need to complete timely quarterly evaluations with data that was relevant to the needs and current condition of the resident was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator), and Staff 11 (Medication Care Manager) on 04/18/24. They acknowledged the findings.

OAR 411-054-0034 (1-6)

Resident Move-in and Eval: Res Evaluation

1. Action taken to correct the rule violation includes:

Resident #4 evaluation has been updated to include to the following required elements.

*Interests, hobbies, social, leisure actitives.

* Mental Health issues including: effective non-drug interventions.

* Recent losses and,

* Alcohol Use

2. The system will be corrected by ensuring that the initial move-in evaluation form will be completed in it's entirety prior to a Residents move-in to ensure all required elements are addressed per OAR. The evaluation will be reviewed prior to 30 days of move in, quarterly, and with significant change of condition thereafter.

3. This area will need to be evaluated with each initial move in evaluation and every subsequent evaluation after that.

4. Facility Administrator, Nursing, or designee will be responsible for completion and monitoring.

2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including Corticobasal Syndrome (asymmetric involuntary movements).

Observations and interviews with the resident, interviews with staff, review of the resident's service plan, dated 03/12/24, and progress notes, dated 02/19/24 through 04/11/24, were completed.

The resident's service plan was not reflective and lacked resident-specific direction for staff in the following areas:

*Mental health including hallucinations and anxiety;

*Cognition;

*Communication;

*Skin;

*Nutrition habits; and

*Emergency and evacuation ability.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator) and Staff 11 (Medication Care Manager) on 04/18/24. No additional information was provided.

3. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.  

The resident's service plan, dated 03/20/24, Short Term Observation and Temporary Service Plans, and progress notes dated 01/08/24 through 04/14/24, were reviewed.

Resident 3 was observed, and the resident's family and staff were interviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* The use of briefs;

* Amount of times staff do safety checks;

* Sleep schedule;

* What time s/he was escorted to breakfast;

* Skin monitoring relating to blood thinner medication;

* Re-orientation assistance needed;

* Hands-on with verbal cueing for evacuation and not leaving the resident alone when at the designated point of safety;

* Ways the resident expressed that s/he would like to leave the building;

* Interventions staff used when the resident was communicating that s/he intends on leaving the facility;

* Refusals to use walker;

* Interventions for refusals to shower;

* Bathing assistance provided including music and soft lighting;

* Independence with grooming; and

* Activity preference both inside his/her apartment and in the facility.  

The need to ensure the service plan was reflective of the resident's current status and included clear directions to staff was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

4. Resident 2 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, long term use of insulin, presence of cardiac pacemaker, and major depressive disorder.

Interviews with resident and staff, and review of the current service plan, dated 03/04/24, revealed Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Assistance needed with mobility;

* Presence of depression, thought disorders, behavioral and mood problems;

* Monitoring instructions relating to the signs and symptoms of depression while on an anti-depressant therapy;

* Number of staff needed to assist with emergency evacuations;

* Instructions on edema management; and

* Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions.

The need to ensure the service plan reflected residents current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/18/24. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, provided clear direction to staff regarding the delivery of services, or was implemented for 4 of 5 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, anemia, cardiac disorder, and dementia.

The resident's current service plan, dated 03/19/24, was reviewed, observations were made, and interviews were conducted. The service plan was not reflective of the resident's needs and preferences, did not provide clear instruction to staff, or was not implemented in the following areas:

* Ability to self-direct care;

* Communication and how to make needs known;

* Orientation status;

* Ability to use pendent and emergency pull cord;

* Dietary, hydration, and meal assist;

* Assistive devices used and instruction to staff;

* Preferred social settings, activity interest and participation;

* Mobility and escorts;

* Toileting assistance;

* Incontinence care;

* Daytime and nighttime wellness checks;

* Monthly vitals;

* Grooming and dressing assistance;

* Medication and treatment administration;

* Fall risk interventions; and

* Emergency and evacuation ability.

The need to ensure service plans were reflective of resident preferences and needs was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator), and Staff 11 (Medication Care Manager) on 04/18/24. They acknowledged the findings.

OAR 411-054-0036 (1-4)

Service Plan: General

1. Actions taken to correct the rule violation are as follows:

    a. Resident #1 service plan has been updated to be reflective of the resident's needs and preferences, and clear instruction to staff in the following areas:

*Ability to self direct;

* Communication and how to make needs known;

* Orientation status;

* Ability to use pendent and emergency pull cord;

*Dietary, hydration, and meal assist;

* Assistive devices used and instruction to staff;

* Preferred social settings, activity interest and participation;

* Mobility and escorts;

* Toileting assistance;

* Incontinence care;

* Daytime and nighttime wellness checks;

* Monthly vitals;

* Grooming and dressing assistance;

* Medication and treatment administration;

* Fall risk interventions; and

* Emergency and evacuation ability.

    b. Resident #4 service plan has been updated to be reflective of resident specific direction for staff in the following areas:

* Mental health including hallucinations and anxiety;

*Cognition;

* Communication;

* Skin;

* Nutrition habits; and

Emergency and evauation ability.

    c. Resident #3 service plan has been updated to be refective of the resident's current status with clear direction for staff in the following areas:

* The use of briefs;

* Amount of times staff to do safety checks;

* Sleep schedule;

* What time resident will be escorted to breakfast;

* Skin monitoring related to blood thinning medication;

* Re-orientation assistance needed;

* Hands on verbal cueing for evaucation and not leaving the resident alone at the designated point of safety.

* Ways the resident expresses the desire to leave the building;

* Interventions staff used when resident is communicating the intent to leave the facility;

* Refusals to use walker;

* Interventions for refusals to shower;

* Bathing assistance provided including music and soft lighting;

* Independence with grooming and;

* Activitiy preference both inside apartment and in the facility.

    d. Resident #2 service plan has been updated to be reflective of the resident's current status with clear direction for staff in the following areas:

* Assistance needed with mobility;

* Presence of depression, thought disorders, behavioral and mood problems;

* Monitoring instructions relating to the signs and symptoms of depression while on an antidepressant therapy.

* Number of staff needed to assist with emergency evacuations.

* Instructions on edema management and;

*Pacemaker precautions, instructions for proper maintenance, and hoe to monitor malfunctions.

2. The system will be corrected so this violation does not happen again by ensuring that the service plan is created to reflect the Residents current status prior to  move in, within 30 days, every 90 days thereafter or with any significant change of condition per company policy and Oregon State Rule.

All updates to the service plan should be initialed and dated. Leadership to provide observations to ensure service plans are being followed.

All resident service plans should be reviewed and updated to reflect any changes or personalization via "Temporary service plan". Clinical staff, care staff, Administrator and resident participate with this process to ensure accuracy, as well as family upon approval/request by the resident. All updates to the service plan are placed in the 24 hr. book for all staff to review and sign off on.

3. The area needing correction will be evaluated quarterly. Changes to service plans will be reviewed daily in Stand up meeting to ensure accuracy and appropriateness, and make changes as needed.

4. Facility Administrator, Nursing, or designee will be responsible for completion and monitoring.

2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including Corticobasal Syndrome (asymmetric involuntary movements).

Resident 4's service plan, dated 03/12/24, and progress notes, dated 02/19/24 through 04/11/24 were reviewed. Observations were made and care staff were interviewed during the survey.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident and/or progress noted at least weekly through resolution:

* 02/19/24, the resident moved into the facility and was placed on alert charting;

* 03/30/24, new psychotropic medication; and

* 04/04/24, the resident was noted to have hallucinations.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined and progress noted at least weekly through resolution was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator) and Staff 11 (Medication Care Manager) on 04/18/24. No additional information was provided.

3. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.

The resident's service plans, dated 03/20/24 and 01/31/24, Short Term Observation and Temporary Service Plans, incident reports, and progress notes dated 01/08/24 through 04/14/24, were reviewed. Resident 3 was observed, and the resident's family and staff were interviewed.

The following short-term changes of condition lacked documentation of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution.

* 11/08/24: The resident had an unwitnessed fall, which resulted in bruising to his/her back and "bump/swelling on back of head". Resident 3 was sent to the hospital and alert charting was started relating to the "Return from ER/ED" which ended on 12/04/23. There was no documented evidence the resident's skin issues were monitored.  

* 03/06/24: The resident went across the street to the grocery store, became disoriented and could not find his/her way back to the facility without a third party intervention. Resident 3 fell in a parking lot which resulted in a right wrist fracture and a cut lip.

On 04/17/24 and 04/18/24, Staff 1 (Executive Director) and Staff 5 (Assisted Living Coordinator) provided survey with updated information that provided direction to staff in case Resident 3 attempted to leave the facility again.

In an interview on 04/18/24 at 10:00 am, Witness 1 (Family Member) verified the resident had not attempted to leave the facility prior to 03/06/24 and had not left the facility without a family member since the incident occurred.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored at least weekly through resolution was discussed with Staff 1, Staff 4 (RN/Wellness Director), and Staff 5 on 04/19/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 3 of 4 sampled residents (#s 2, 3, and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, long term use of insulin, presence of cardiac pacemaker, and major depressive disorder.

Clinical records, including the resident's current service plan and observation notes from 01/02/24 through 04/11/24, were reviewed, and interviews with the resident and facility staff were conducted. Resident 2's progress notes revealed the following:

* 01/21/24, the resident had a visit to urgent care and started antibiotic therapy related to a Urinary Tract Infection (UTI);

* 02/09/24, "PCP recommends diabetic diet ..." related to the elevated blood glucose level;

* 03/27/24, start antibiotic therapy related to UTI;

* 03/29/24, discontinue amlodipine (for blood pressure), losartan (for blood pressure), and start entresto (for blood pressure) for 30 days;

* 04/02/24, CBG of 549 which constituted elevated CBG;

* 04/05/24, physician order to discontinue Lantus (insulin injection);

* 04/05/24, increase Lantus to 15 units; and

* 04/05/24, physician order to start Lasix (diuretic) twice weekly on Monday and Friday.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, or documented weekly progress until the condition resolved.

The need to ensure the facility determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/18/24. They acknowledged the findings. No further information was provided.

OAR 411-054-0040 (1-2)

Change of Conditon and Monitoring

1. Actions taken to correct this rule violation area as follows:

    a. Resident #4 had a focused assessment completed by the licensed nurse psychotropic medication and hallucinations.

    b. Resident #3 has a focused assessment completed by the licensed nurse related to falls, skin issues, disorientation and interventions.

2. To ensure the system will be corrected so this

violation will not happen again, a 24-hour

communication system will be in place to include:

1. Shift to Shift Communication Log

2. Alert Charting Log / Audit Log

3. Significant Change of Condition Log

4. Weekly Skin Monitoring Log

    a.Staff will start short term monitoring /

communication system for any resident identified

to have an acute change of condition such as

skin events, increased confusion, return from the hospital, or fall for example.

    b. The Staff will be aware of what to report to

Nurse/MD per the temporary service plan (TSP) that has been put in place, which cooralates with the Residents change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

    c. Staff should monitor Resident status until

Resident condition resolves and they are back at their

baseline.

    d. 24 hour book / process will be reviewed daily

during stand-up meeting as a means of identification of

potentail significant change that needs to be assessed

by the RN.

3. System will be reviewed daily, weekly, monthly and

quarterly to ensure compliance is maintained.

4.The Facility Administrator and Registered Nurse will

be responsible for ensuring the system has been

corrected and is monitored.

2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia.

The resident's clinical record was reviewed and revealed Resident 1 experienced weight fluctuations between 01/2024 through 03/04/24. Weight records showed the following:

* 01/10/24: 149 pounds;

* 01/05/24: 202.4 pounds;

* 02/28/24: 150.2 pounds; and

* 03/04/24: 149.9 pounds.

Resident 1 was documented to experience a weight loss of 52.2 pounds in one month, or 25 % of his/her body weight. This constituted a significant change of condition requiring an RN assessment.  

There was no documented evidence the RN completed an assessment which included findings, resident status, and interventions made as a result of the assessment related to weight loss.

On 04/17/24, the resident was observed to require assistance with eating and ate approximately 25% during the noon meal.

In an interview with Staff 4 (RN/Wellness Director) on 04/17/24 at 11:22 am, she stated she was not notified of the weight fluctuation and believed there was an error in the documentation. Staff 4 acknowledged there was no RN assessment conducted related to the resident weight fluctuations.

The need to ensure an RN conducted an assessment that included findings, status and interventions when a resident experienced a significant change of condition was reviewed with  Staff 1 (Executive Director), Staff 5 (Assisted Living Coordinator) and Staff 11 (Medication Care Manager) on 04/18/24. No additional information was provided.

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

1. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.  

Observations of the resident, and interviews with the resident's family and staff were conducted. Resident 3's service plan dated 03/20/24, Short Term Observation and Temporary Service Plans, incident investigations, and progress notes dated 01/08/24 through 04/14/24, were reviewed.

On 03/06/24, the resident left the facility to go to the grocery store that was across the street. Resident 3 became disoriented and was not able to find his/her way back to the facility, without a third party intervention. The resident fell in a parking lot and sustained a fractured wrist.  

The increased confusion and right wrist fracture constituted a significant change in condition for Resident 3.

An RN significant change of condition assessment was completed five days after the event, and lacked the resident's status, interventions related to the fracture and Resident 3's cognition.

The need to ensure an RN assessed all significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

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

Resident Health Services

1. Action taken to correct this rule violation includes;

    a. Resident #3 will have a comprehensive signifcant change of condition assessment specific to increased confusion and right wrist facture which will include the residents' current status and interventions. Resident will have on-going follow up related to this changes until new baseline can be established or resident returns to historical baseline.

    b.Resident #1 will have a comprehensive signficant

change of condition assessment specific to significant

weight loss and interventions added to service plan to

minimize the risk of complications related to weight

loss and interventions to minimize the continued risk of

loss as appropriate. Resident will have on going

nursing follow up related to this change until new

baseline can be established or resident returns to

historical baseline.

2. To ensure the system will be corrected so this

violation will not happen again includes;

The community will follow 24 hr communication system. The "24 hr binder" has been set up to include:

1) Shift to Shift Communication LOG

2) Alert charting log/audit tool

3) Significant change of condition LOG

4) Weekly Skin Monitoring Log

    a. Staff will follow Short Term Montoring / Communication System for any Resident

identified to have an acute change of condition such as

increased confusion, missed med, return from hospital, fall for example.

When a change of condition is identified, Staff add the

Residents name to the alert log to ensure they monitor

the Resident and identify when to report concerns to

Nursing or MD.

b. The Staff will be aware of what to report to

Nurse/MD per the temporary service plan (TSP) that has been put in place, which cooralates with the Residents change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

c. Staff should monitor Resident status until

Resident condition resolves and they are back at their

baseline.

d. 24 hour book / process will be reviewed daily

during manager meeting as a means of identification of

potentail significant change that needs to be assessed

by the RN.

3. System will be reviewed daily, weekly, monthly and

quarterly to ensure compliance is maintained.

4.The Facility Administrator and Registered Nurse will

be responsible for ensuring the system has been

corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (# 2) who received insulin injections by a facility unregulated assistive person (UAP). Findings include, but are not limited to:

Pursuant to OAR chapter 851 division 006, delegation process means the process utilized by an RN to authorize an UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions and outcomes pursuant OAR 851-045 including comprehensive assessment, reasoned conclusions that identify client problems and risks, educate the UAP and evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client.

During the acuity interview on 04/16/24, Resident 2 was identified to be administered an insulin injection once daily by a facility UAP.

Resident 2's MARs from 03/01/24 through 04/16/24 revealed insulin injections had been given by Staff 10 (Medication Care Manager), Staff 15 (Medication Care Manager), and Staff 17 (Medication Care Manager).

Review of the nursing delegation binder found no documented evidence the initial nursing delegation was completed for Staff 10 and Staff 17. The initial nursing delegation for Staff 15 was dated 02/27/24.

Additionally, the RN comprehensive assessment to determine Resident 2's condition was stable and predictable, one of the criteria for delegation of a nursing procedure, was not dated.

During the interview on 04/17/24, Staff 4 (RN/Wellness Director) confirmed Staff 10 and Staff 17 were not delegated to prepare and administer insulin injections for Resident 2. On 04/17/24 at 5:15 pm, Staff 4 provided the survey team with an immediate plan for nursing delegation which indicated Staff 15 will be the only UAP to prepare and administer insulin. Staff 4 informed the survey team that she planned to conduct initial nursing delegation for Staff 10 on 04/19/24 during the scheduled evening shift and Staff 17 during that staff member's next scheduled shift. Staff 4 verbalized understanding that the facility RN had responsibility for all nursing tasks administered by UAPs in the facility.

The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by a RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 was reviewed with Staff 1 (Executive Director) and Staff 4 on 04/18/24. They acknowledged the findings. No further information was provided.

OAR 411-054-0045 (1)(f)(B)

RN Delegation and Teaching

1. Action taken to correct this rule violation is as follows:

    a. Staff #10 and Staff #17 has had their initial nursing delegation for Resident #2 completed by the Registered Nurse.

    b. Staff #15 has had delegation updated for Resident #2 by the Registered Nurse.

2. To correct the system the violation does not happen again, the delegation log has been updated and a copy will be kept in the medication room for all med techs to share accountability with schedule/ plan to re-delegate.   A comprehensive delegation audit will be completed to ensure delegation and supervision of special tasks of nursing care are being done consistently in accordance with OSBN Administrative Rules.

3.The area needing correction will be evaluated on a monthly basis, utilizing the Delegation audit tool and updating delegation log monthly and as needed.

4. The RN will be responsible to see that the corrections are completed and monitored.

2. Resident 2 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, long term use of insulin, presence of cardiac pacemaker, and major depressive disorder.

Review of Resident 2's current facility records and MARs from 03/01/24 to 04/16/24 revealed the following:

Resident 2's current facility records included a physician order dated 03/08/24 to "check CBG BID, notify [physician] if greater than 250 or less than 90," and a physician order dated 04/05/24 to "notify PCP for CBG less than 90 and/or above 400."

Review of MARs showed the following:

* Resident's CBG in the evening from 03/08/24 to 04/05/24 was above 250 on 42 occasions; and

* Resident's CBG in the evening from 04/06/24 to 04/16/24 was above 400 on one occasion.

There was no documented evidence the resident's physician was notified during 03/2024 of the excessive CBG on 41 occasions, and during 04/01/24 through 04/16/24 on one occasion.

The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/18/24. They acknowledged the findings. No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications the facility was responsible for administering for 2 of 5 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, anemia, cardiac disorder, and dementia.

The resident's 04/01/24 to 04/16/24 MAR and most recent physician orders dated 11/19/23 were reviewed. The following was identified:

a. The physician orders noted to administer each scheduled daily medication at "08:00". The MAR noted to administer medication at "AM-During Time Frame" and did not identify when the medication was administered. The medication administration time was documented in the "Med Pass History," where the past three days of medication administration times were reviewed, and the following was revealed:

* 04/16/24: scheduled medications were administered at 10:10 am and 10:15 am;

* 04/17/24: scheduled medications were administered at 09:41 am; and

* 04/18/24: scheduled medications were administered at 09:55 am.

In an interview with Staff 5 (Assisted Living Coordinator) and Staff 11 (Medication Care Manager) on 04/18/24, they stated they were not aware the physician's orders had administration times identified.

b. There was a physician's order to administer "Bisacodyl 10 mg suppository" if there had been "no bowel movement for [two] days." The April 04/01/24 through 04/16/24 MAR  identified the medication had not been administered.

In an interview with Staff 11 on 04/17/24, she stated she was unaware how bowel movements were monitored.

On 04/18/24, Staff 4 (RN/Wellness Director) and Staff 5 confirmed the facility did not have a system in place to ensure the medication was administered as ordered.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Executive Director), Staff 4, Staff 5, and Staff 11 on 04/18/24. They acknowledged the findings.

OAR 411-054-0055 (1)(f-h)

Systems: Treatment Orders

1. Action taken to correct the rule violation is as follows:

    a. Resident #3 MAR has been updated to be reflective of specific times of medication administration.

    b. Resident #2 provider has been faxed CBG results for the months of March 2024 and April 2024.

2.The system will be corrrected so this violation will

not happen again by all resident and treatment orders

will be reconciled to ensure medications and

treatments are dispensed as ordered.

3. Medication reconcilations will be completed upon

resident move-in, and quarterly basis. Additionally, all

new orders will be reviewed and approved by a

minimum of three staff, Further daily audits to review

missing medications, ommissions and PRN usage will

be completed.

4. The Administrator, Licensed Nurse or trained designee will be responsible to ensure the corrections are completed and monitored.

2. Resident 4 was admitted to the facility in 02/2024 with diagnoses including Corticobasal Syndrome (asymmetric involuntary movements).

Resident 4's 04/01/24 through 04/16/24 MAR was reviewed and noted facility staff documented the resident refused the following order:

* Quetiapine (for agitation) on eight occasions.

During an interview on 04/17/24 at 11:00 am, Staff 11 (Medication Care Manager) verified there was no documented evidence Resident 4's physician had been notified related to medication refusals.

Notifying the physician related to medication refusals was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator) and Staff 11 on 04/18/24. No additional information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to an order for medication administration and daily weight checks for 2 of 2 sampled residents (#s 2 and 4) reviewed with documented refusals. Findings include, but are not limited to:

1. Resident 2's MARs from 03/01/24 through 04/16/24 and corresponding progress notes were reviewed. The resident's records showed the following treatment refusals:

* Daily weights from 03/18/24 through 04/16/24, eleven times.

There was no documented evidence the facility notified the physician or other practitioner each time the resident refused consent to the orders.  

The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/18/24. They acknowledged the findings. No further information was provided.

OAR 411-054-0055 (1)(j-k)

Systems: Resident Right to Refuse

1. Actions taken to correct this violation are as follows:

    a. Resident #2 weight refusals from 3/18/24 through 4/16/24 have been faxed to provider.

b. Resident #4 medication refusal of quetiapine from 4/1/24 through 4/16/24

2. The system will be corrected so this violation does not happen again by:

    a. All resident providers have been faxed requesting when they would like to be notified of any missed / refused medications / treatments.

    b. When faxes are received back the provider preferences will be added to the MAR for med tech's to follow the instructions and sign out on the MAR.

3. This will be audited daily, weekly and monthly by the Licensed Nurse, RCC and / or designee.

4. The Administrator, Licensed Nurse and / or designee will be responsible for ensuring corrections are completed and monitored.

2.  Resident 4 was admitted to the facility in 02/2024 with diagnoses including Corticolbasal Syndrome (asymmetric involuntary movements).

A review of Resident 4's 04/01/24 through 04/16/24 MAR identified the following medications lacked reasons for use:

* Atorvastatin;

* Donepezil;

* Folic Acid;

* Mirtazapine;

* Paroxetine; and

* Vitamin D3.

The need to ensure MARs included reason for use for all medications was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), Staff 5 (Assisted Living Coordinator) and Staff 11 (Medication Care Manager) on 04/18/24.  No additional information was provided.

3. Resident 3 was admitted to the facility in 05/2023 with diagnoses including Alzheimer's disease.  

The resident's 04/01/24 through 04/16/24 MAR and physician's orders were reviewed.

a. There was no direction to staff on the sequential order of PRNs used to treat the same diagnosis for the following medications:

* Acetaminophen for pain;

* Ibuprofen for pain; and

* Icy Hot cream for pain.

b. The following medications lacked a reason for use:

* Amiodarone;

* Digoxin;

* Eliquis;

* Entresto;

* Levothyroxine;

* Rosuvastatin; and

* Sertraline.

The requirement for MARs to be accurate and include medication specific instructions and resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 01/2024 with diagnoses including chronic obstructive pulmonary disease and throat cancer.

The resident's 04/01/24 through 04/16/24 MAR and physician's orders were reviewed.

a. The following PRN medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:  

* Bisacodyl, enema, lactulose, polyethylene glycol, and senna for constipation;

* Hydroxyzine and lorazepam for anxiety; and

* Lorazepam, midazolam, and morphine for shortness of breath.

b. The following medications lacked a reason for use:

* Betamethasone ointment;

* Breyna inhaler;

* Polyethylene glycol;

* Spiriva Respimat inhaler;

* Lactulose;

* Secura Protect cream; and

* Senna.

During an interview on 04/18/24 at 12:50 pm, Staff 11 (Medication Care Manager) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff. Staff 11 also confirmed the electronic MAR lacked reasons for use for the above medications.

The need to ensure resident's MAR was accurate and included resident specific parameters and staff instructions was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

5. Resident 2 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, long term use of insulin, presence of cardiac pacemaker, and major depressive disorder.

Resident 2's MARs from 03/01/24 through 04/16/24 and physician orders were reviewed and revealed the following:

a. The following medications lacked documented reasons for use:

* Jardiance;

* Metoprolol;

* Venlafaxine;

* Vitamin B 12;

* Docusate; and

* Fluticasone.

b. The order for PRN Albuterol inhaler (for shortness of breath) was entered twice.

The need to ensure MARs for each resident that the facility administers medications to included reason for use and resident-specific parameters was reviewed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director), and Staff 5 (Assisted Living Coordinator) on 04/18/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication specific instructions, and had resident-specific parameters and instructions for PRN medications for 5 of 5 sampled residents (#s 1, 2, 3, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including type 2 diabetes mellitus, anemia, cardiac disorder, and dementia.

Resident 1's MAR dated 04/01/24 through 04/16/24 was reviewed during survey and revealed the following:

a. The MAR lacked the reason for use of the following scheduled medications:

* Acetaminophen;

* Fluoxetine; and

* Furosemide.

During an interview with Staff 11 (Medication Care Manager) on 04/17/24 at 1:38 pm, she confirmed the scheduled medications did not have a reason for use.

b. There was no documented evidence of specific instruction to staff regarding side effects for all medications.

c. The following PRN medications prescribed for constipation lacked resident-specific parameters and instructions to staff:

* Bisacodyl suppository;

* Docusate sodium;

* Polyethylene glycol; and

* Senna.

During an interview with Staff 4 (RN/Wellness Director) on 04/18/24 at 11:35 am, she confirmed the PRN medications lacked resident-specific parameters or instructions for unlicensed staff.

The need to ensure MARs were accurate, included medication specific instructions, and had resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 4, Staff 5 (Assisted Living Coordinator), and Staff 11 on 04/18/24.  They acknowledged the findings.

OAR 411-054-0055 (2)

Systems: Medication Adminsitration

1. Actions taken to correct the rule violation is as follows:

    a. Resident #1 MAR has been updated to be reflective of the reason for use and side effects for

* Acetaminophen;

* Fluoxetine; and

* Furosemide.

and

The following as needed medications are reflective of resident-specific parameters and instructions to staff:

* Bisacodyl Suppository

* Docusate Sodium

* Polyethylene Glycol; and

* Senna

    b. Resident #4 MAR has been updated to be reflective of the reason for use for:

* Atorvastatin;

* Donepezil;

* Folic Acid;

* Mirtazapine;

* Paroxetine; and

* Vitamin D3

    c. Resident #3 MAR has been updated to be reflective of order of medication for the following as needed medication with the same reason for use with clear instructions:

* Acetaminophen for pain;

* Ibuprofen for pain; and

* Icy Hot Cream for pain.

and

The MAR has been updated to be reflective of the reason for use for:

* Amiodarone;

* Digoxin;

* Eliquis;

* Entresto;

* Levothyroxine;

* Rosuvastatin; and

* Sertraline.

    d. Resident #5 MAR has been updated to be reflective of resident specific parameters and intructions with order of administration for the following as needed medications

* Bisacodyl, emema, lactulose, polyethylene glycol, and senna for constipation.

* Hydroxyzone and lorazepam for anxiety, and

* Lorazepam, midazolam, and morphine for shortness of breath.

and

The MAR has been updated to be reflective of the reason for use for:

* Betamethasone ointment;

* Breyna inhaler;

* Polyethylene glycol;

* Sprivia Respimat inhaler;

* Lactulose;

Secura Protect cream; and

Senna

2.The system will corrected so this violation will no

happen by ensuring trained community staff perform

daily MAR audit to ensure all medicaitons have reason for use, order of administration for multiple medication with the same reason for use, with specific parameters and instructions All new physician orders go through a triple check where the order is initially processed by the

receiving med tech / RCC to ensure no delay of

treatment. Second check is the next oncoming med

tech / RCC to verify orders are accurate, and

appropriate directions and parameters for staff to follow

are in place. Nursing or designee to be the final check to verify all components are in place, and to make updates as indicated.

Trained staff will complete weekly and monthly MAR

aduits to ensure any concerns with medication

decrepancy, omissions, PRN effectiveness, and

parameteres are followed up on timely.

3. The area needed correction will be reviewed daily,

weekly, and monthly basis with triple check. MAR audits and monthly continuous quality improvement program. All orders will be reconciled quarterly prior to physician orders sent to MD for review.

4. The Administrator, Licensed Nurse, or trained

designee will be responsible to ensure the corrections

are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications and have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (# 5) who chose to self-administer their medications. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 01/2024 with diagnoses including chronic obstructive pulmonary disease and throat cancer.

Review of Resident 5's 04/01/24 through 04/16/24 MAR noted the following medications were not administered by the facility:

* Albuterol nebulizer (for wheezing, shortness of breath) four times daily;

* Azelastine nasal spray (no reason documented) twice daily;

* Betamethasone ointment (no reason documented) once daily;

* Breyna inhaler (no reason documented) twice daily;

* Clindamycin topical solution (for acne) twice daily; and

* Spiriva Respimat inhaler (no reason documented) twice daily.

During an interview on 04/17/24 at 9:50 am, Resident 5 stated s/he managed his/her own inhalers, the nebulizer, nasal spray, and topical medications. The Albuterol nebulizer, Spiriva Respimat, and Breyna inhalers were observed in the resident's apartment.

There was no documented evidence an evaluation of Resident 5's ability to administer their own medications had been completed. There was a current physician order dated 03/11/24 to self administer the Breyna inhaler. However, there was no documented evidence of current prescriber orders to self-administer the remainder of the medications.

During an interview on 04/17/24 at 11:00 am, Staff 4 (RN/Wellness Director) confirmed there was no evaluation completed for self-administration of medication nor were there current physician orders for the remainder of the medications.

The lack of physician orders and evaluation for self-administration of medications was discussed with Staff 1 (Executive Director), Staff 4, and Staff 5 (Assisted Living Coordinator) on 04/19/24. They acknowledged the findings.

OAR 411-054-0055 (5)

Systems: Self-Administration of Meds

1. Actions taken to correct this rule violation is as follows:

* Resident #5 provider has approved the resident to self administer albuterol nebulizer, azelastine nasal spray, betamethasone ointment, breyna inhaler, clindamycin topical solution, and spirivia respimat inhaler and a self medication evaluation has been completed.

2.To ensure that this violation does not re-occur all

residents that have medications or treatments in their

apartments and / or orders from their providers will be evaluated for self administration and obtain subsequant physician orders for them.

3. This system needing corrected will need to be

evaluated on a quarterly basis or with significant

change of condition with all residents med reviews and

update to self med evaluation.

4. The Licensed Nurse or designee will be responsible to ensure the corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure a thorough RN, PT, or OT assessment was completed prior to the use of a supportive device with restraining qualities, document other less restrictive alternatives were evaluated prior to the use of the device, instruct caregivers on the correct use and precautions related to the use of the device, and include the use of the supportive device on the service plan for 1 of 1 sampled residents (# 4) who used a supportive device with restraining qualities. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2024 with diagnoses including Corticolbasal Syndrome (asymmetric involuntary movements).

On 04/16/24, a hospital bed was observed to have bilateral, three quarter-length siderails. One siderail was in the up position and was securely fastened to the bed and the siderail near the recliner was in the down position.

Review of Resident 4's service plan dated, 03/12/24, revealed there was no documentation of the use of supportive devices with restraining qualities included in the resident service plan.

In an interview on 04/17/24 at 9:10 am, Staff 14 (Care Manager) stated the siderails were used to help keep the resident positioned in bed.

During an interview on 04/17/24 at 1:30 pm, Staff 4 (RN/Wellness Director) verified there was no documented evidence an assessment of the device with restraining qualities had been completed.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and documentation of their use was included in the resident service plan was discussed with Staff 1 (Executive Director), Staff 4, Staff 5 (Assisted Living Coordinator), and Staff 11 (Medication Care Manager) on 04/18/24. No additional information was provided.

OAR 411-054-0060

Restraints and Supportive Devices

1. Action taken to correct this rule violation includes;

Resident #4 will have an RN assessment completed for the use of her bilateral side rails and service plan will be updated to reflect the use of the bilateral side rails.

2. This system is being corrected to eliminate future violations, as follows:

    a. Facility has conducted a facility walk-through to identify all supportive devices in use.     

    b. Facility RN will ensure that all current support devices have a valid written order from the provider, are part of the resident service plan, and an assessment that includes the following:

    (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and

    (b) The facility registered nurse, a physical therapist

or occupational therapist has conducted a thorough assessment; and

    (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and

    (d) The facility has instructed caregivers on the correct use and precautions related to use of the device.

    (e) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis or with a significant change of condition.

    c. Facility RN will keep a log of all supportive supportive devices, to ensure that timely assessments are completed, on schedule.

    d. Facility RN will provide training via in-service on proper use of bed-rails and other supportive devices.

3. This system will be evaluated as follows:

    a. With each new admission, as applicable, quarterly and / or with a signifcant change of condtion.

4.The Administrator, Licensed Nurse or designee will be responsible for ensuring the correction is completed and montiored.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (Executive Director), Staff 4 (RN/Wellness Director) and Staff 5 (Assisted Living Coordinator) on 04/17/24. They reported the ABST was driven by the service plan for each resident.

There was no documented evidence all 22 of the required ADLs were addressed in the ABST used by the facility. Additionally, the facility did not routinely update the facility's staffing plan based on changes to the ABST outputs, nor did the ABST generate a specific number of weekly care minutes required to meet the 24-hour scheduled and unscheduled needs of residents. Instead, the facility's service plans generated a number of "care points" that were translated by the facility into aggregate care hours and were not found to be reflective of the time needed for all 22 ADL elements.

The need to ensure the facility uses an ABST which met the regulation was discussed with Staff 1, Staff 4 and Staff 5 on 04/18/24. They acknowledged the findings. No further information was provided.

OAR 411-054-0037 (1-8)

Acuity-Based Staffing Tool

1. Action taken to correct this rule violation is as follows:

    a. The facility is using its inhouse ABST tool algorithm located within the ALIS Software.

    b. The ABST tool pulls the service plan point system from all residents and calculates appropriate staffing based on the acuity of each individual resident.

    c. Using the staffing schedule assisgnments to assure staffing in accordance to the the ABST tool.

2. This system is being corrected to eliminate future violations, as follows:

    a. Facility corporate working to create policies / procedures related to the ABST.

    b. Facility IDT will receive training related to

the requirements of the Acuity-Based Staffing Tool,

    c. Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation and / or with any significant change of condition

    d. Facility Administrator will review staffing schedule to ensure that the schedule is reflective of staffing requirements based on the ABST.

3. This system will be evaluated as follows:

    a. Facility will update the ABST with each resident evaluation: initial, 30-days, quarterly, and with significant change of condition,

    b. Facility Administrator will review monthly staffing schedule to ensure that schedule is reflective of staffing needed per the ABST at least once monthly.

4.  Facility Administrator, Licensed Nurse and / or RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure 7 of 7 staff members (#s 7, 8, 15, 16, 17, 20, and 23) had completed the Home and Community Based Services (HCBS) training by 03/31/24. Findings include, but are not limited to:

Staff training records were reviewed on 04/17/24.

Staff 7 (Housekeeper), hired 09/01/21, Staff 8 (Care Manager), hired 02/05/24, Staff 15 (Medication Care Manager), hired 01/02/24, Staff 16 (Care Manager), hired 01/02/24, Staff 17 (Medication Care Manager), hired 01/21/22, Staff 20 (Server), hired 04/24/22, and Staff 23 (Life Enrichment Assistant), hired 01/29/24, lacked documented evidence of completing the HCBS training.

The need to ensure staff completed the HCBS training by 03/31/24 was discussed with Staff 1 (Executive Director) and Staff 3 (Business Office Manager) on 04/17/24. They acknowledged the findings.

OAR 411-054-0070 (3-4)

Staffing Rqmts and Training: Caregiver Reqmts

1. Action taken to correct this rule violation are as follows;

Staff #7, Staff #8, Staff #15, Staff #16, Staff #17, Staff #20 and Staff #23 will completed the Home and Community Based Services (HCBS) training.

2. System will be corrected so that violation will not

happen again by;

    a. Comprehenisve training record audit of all

trainings and competencies completed and

documneted on a training log for review.

    b. Any missing competencies and training will be

completed for currently employed staff.

3. The area needing correction will need to be evaluated with each new hire as part of their on-

boarding process, and on a quarterly basis.

4. The Administrator or designee will be

responsible to see that the corrections are completed

and monitored.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired employees (#s 27, 30, 31 and 32) completed an orientation that included Home and Community-Based Services (HCBS) training. This is a repeat citation. Findings include, but are not limited to:

Employee training records were reviewed on 10/03/24 at 11:00 am with Staff 24 (Interim Administrator).

Staff 27 (Assisted Living Coordinator) was hired 09/03/24; Staff 30 (MT) was hired 08/05/24; Staff 31 (CG) was hired 07/16/24; and Staff 32 (Dining Room Supervisor) was hired 08/27/24.

None of the sampled staff had documented evidence they completed HCBS training prior to beginning job responsibilities.

The need to ensure employees completed HCBS as part of new-hire orientation was discussed with Staff 24 and Staff 26 (Chief Wellness Officer) on 10/03/24. They acknowledged the findings.

OAR 411-054-0070 (3-4)

Staffing Rqmts and Training: Pre-Service

1. Action taken to correct this rule violation are as follows;

Staff #27, Staff #30, Staff #31, Staff #32, completed Home and Community Based Services Training (HCBS).

 a. Training record aduit of all staff has been completed utilizing ODHS QM Staff Training Tracker tool.

 b. All missing pre-service training has been completed for currently employed staff.

2. The system will be corrected so that violation will not

happen again by;

 a. A weekly review of pre-service training completions, including HCBS, for new direct care staff members will be conducted, using the Staff Training Tracker, to determine if staff member qualifies to begin performing their job responsibilities.

3. The area needing correction will need to be evaluated weekly with each new hire.

4. The Administrator, Assisted Living Coordinator and  Business Office Manager will be

responsible to see that the corrections are completed

and maintained.

Based on interview and record review, it was determined the facility failed to ensure 4 of 9 sampled medication technicians (#s 14, 30, 33 and 34) demonstrated knowledge and performance in any duty they were assigned prior to providing care services to residents. The four identified MTs were working independently and lacked documentation of competency in medication administration, which put residents for which they administered medications at risk for serious harm. Findings include, but are not limited to:

Employee training records were reviewed on 10/03/24 at 11:00 am with Staff 24 (Interim Administrator).

Staff 14 (MT) was hired 10/16/23; Staff 33 (MT) was hired 06/10/24; Staff 34 (MT) was hired 07/01/24; and Staff 30 (MT) was hired 08/05/24. Each of these staff had been working in the facility independently as an MT, which included administering medications to residents. The facility was unable to provide documentation that their knowledge and performance in administering medications had been reviewed and each had been determined competent to administer medications unsupervised.

On 10/03/24 at 12:55 pm, the survey team requested an immediate plan of correction (POC) to ensure MTs whose job it was to administer medications to residents were trained by appropriate facility staff and there was documentation to show they had observed and evaluated the MT's ability to perform safe medication administration unsupervised. On 10/03/24 at approximately 1:30 pm, the facility submitted a POC that was accepted by the survey team. Staff 28 (Regional RN) immediately evaluated and documented Staff 34's competency to administer medications. The POC included a plan to evaluate and document Staff 14, 30 and 33's competency on the next shifts they were scheduled and prior to them administering medications unsupervised.

The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation.

The need to ensure the facility had a process to ensure all direct care staff had documentation of demonstrated competency in any duty they were assigned was reviewed with Staff 24 and Staff 26 (Chief Wellness Officer) on 10/03/24. They acknowledged the findings.

OAR 411-054-0070 (5 & 9-10) Training

within 30 days: Direct Care Staff

1. Action taken to correct this rule violation are as follows;

All Direct Care Staff, both caregivers and medication managers, have documentation of demonstrated competencies.

2. The system will be corrected so that violation will not

happen again by;

 a. A monthly review of all direct care staff competencies utilizing ODHS QM Staff Training Tracker tool.

 b. Monthly audit a sample of employees to ensure competency documentation matches the Staff Training Tracker tool.

3. The area needing correction will need to be reviewed monthly using the QDHS QM Staff Training Tracker tool.

4. The Administrator, Wellness Director and Assisted Living Coordinator will be responsible to see that the corrections are completed and maintained.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term direct care staff (#s 17, 18, and 19) completed a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours on dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 04/17/24.

Staff 17 (Medication Care Manager), hired 01/21/22, Staff 18 (Care Manager), hired 08/25/21, and Staff 19 (Care Manager), hired 08/25/21, lacked documented evidence of completing a minimum of 12 hours of in-service training annually, based on date of hire, which included six hours on dementia training.

The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including six hours on dementia training, was discussed with Staff 1 (Executive Director) and Staff 4 (Business Office Manager) on 04/17/24. They acknowledged the findings.

OAR 411-054-0070 (2-5)(5-8)

Annual Training and Other Requirements

1. Action taken to correct this rule violation includes:

Staff #17, Staff #18, Staff #19 will complete 12 hours of annual in-service training, included 6 hours of dementia training.

2. System will be corrected so that violation will not

happen again by;

    a. Comprehenisve training record audit of all

trainings and competencies completed and

documneted on a training log for review

    b. Any missing competencies and training will be

completed for currently employed staff.

    c. Staff will utilize a combination of Oregon Care

Partners Programing, medi tech meetings, and monthly

staff meetings to meet the annual in-servicing

requirements

    d. Staff will submit certificates of completion or

evidence of participation at facility provided trainings

for documentation.

3. Area needing correction will be evaluated weekly

and monthly via review of newly hired staff and training

log review.

4. Administrator and/or designee will be responsible to

ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled long-term direct care staff (#s 18 and 19) completed a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care (CBC) setting, including six hours of dementia care training. This is a repeat citation. Findings include, but are not limited to:

Employee training records were reviewed on 10/03/24 at 11:00 am with Staff 24 (Interim Administrator).

Staff 18 (MT) and Staff 19 (CG) were both hired on 08/25/24. Both staff's annual training records had been reviewed on the previous survey and found to be deficient. The records provided during this survey indicated both staff had not completed a minimum of 12 hours of in-service training annually, including six hours on dementia care training.

The need to ensure the facility had a process to ensure direct care staff completed a minimum of 12 hours of in-service training annually, including six hours on dementia care training was reviewed with Staff 24 and Staff 26 (Chief Wellness Officer) on 10/03/24. They acknowledged the findings.

OAR 411-054-0070 (6-8) Annual and Biennial Inservice for All Staff

(6-8) ANNUAL AND BIENNIAL

INSERVICE FOR ALL STAFF.

1. Action taken to correct the rule violation are as follows;

Long-term direct care staff (#s 18 and 19) completed 12 hours of trainings by 10/18/24 that including Home and Community Based Services (HCBS) and six hours of dementia care training using a combination of Oregon Care Partners and Relias.

2. System will be corrected so that violation will not

happen again by;

    a. An  audit of all direct care trainings were completed and documneted utilizing ODHS QM Staff Training Tracker Tool.  

    b. Any missing training were completed for currently employed staff.

    c. Staff will utilize a combination of Oregon Care

Partners Programing, medi tech meetings, and monthly

staff meetings to meet the annual in-servicing

requirements

    d. Staff will submit certificates of completion or

evidence of participation at facility provided trainings

for documentation.

3. Area needing correction will be evaluated weekly

and monthly via review of newly hired staff and training

tracking tool review.

4. Administrator and/or designee will be responsible to

ensure corrections are completed and monitored.

      b. An audit of biennial and annual training was completed for all direct care staff.

      c. All direct care staff needing biennial and annual trainings were completed by 10/18/24, including Home and Community Based Services (HCBS), six hours of dementia care training, LGBTQIA2S+, infectious disease outbreak and infection training using a combination of Oregon Care Partners and Relias.

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

Facility fire drill records dated 10/2023 through 04/2024 were reviewed. The facility lacked documented evidence the unannounced fire drills that were conducted included the following components:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

There was no evidence alternate escape routes were used during fire drills.  

Additionally, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

The need to ensure unannounced fire drills were conducted every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 1 (Executive Director) and Staff 2 (Regional Maintenance Director) on 04/17/24.

On 04/19/24, Staff 1 provided a written fire and life safety plan that outlined the dates of when staff would be instructed on the evacuation of residents and when the actual evacuation drill would occur.

OAR 411-054-0090 (1-2)

Fire and Life Safety: Safety

1. Actions taken to correct the rule violation will

include;

    a. Written fire drill records will be kept that include;

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to particpate in the drills;

* Evaucation time period needed; and

* Number of occupants evacuated.

* Alternate  escape routes used.

2. System will be corrected so that violation will not

happen again by;

    a. Comprehensive review of current fire drill forms

to ensure they meet all required components.

    b. In servicing provided to administration and or

designee conducting fire and life safety drills and

education on process and documentation required.

3. Area needing correction will be evaluated

monthly.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills. This is a repeat citation. Findings include, but are not limited to:

Facility fire drill records dated 06/2024 through 10/2024 were reviewed. The facility lacked documented evidence the unannounced fire drills that were conducted included the following components:

* Escape route used; and

* Evacuation time period needed.

There was no evidence alternate escape routes were used during fire drills.  

There was no evidence fire drills were being conducted on alternate months.

Additionally, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

In an interview on 10/03/24 at 5:15 pm, the need to ensure unannounced fire drills were conducted every other month and included all required components, and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 24 (Interim Administrator) and Staff 26 (Chief Wellness Officer) on 10/03/24. They acknowledged the findings.  

OAR 411-054-0090 (1-2)

Fire and Life Safety: Safety

1. Actions taken to correct the rule violation are as follows;

    a. Fire and Life Safety instruction was provided to all staff on 10/10/24 that included; designated points of safety, alternate exit routes, emergency assemby points, areas of refuge, types of evacuations, roles of direct and non direct care staff during evacutions, and evacuating nonambulatory residents. A walkthrough of the community identifying fire doors and mechaninsms, fire panel, points of refuge, fire extinguishers, safety points outside, and importance of residents signing in/ out of building.

     b. Fire and Life Safety education was provided to residents that included areas of refuge, types of evacuations, outside evacuation safe zones, alternate routes, use of pull alarm, sprinklers, location of smoke detectors and sprinkler in facility and resident apartments, staff duties during evacuation and assistance to residents, and importance of signing in and out of building, as well as a handout covering evacuation procedures.  

   c. Unannouced fire drills scheduled for 10/23/24 and 10/24/24 on alternate shifts utilizing fire drill form that includes;

*Date and time of drill,

*Location of simulated fire origin,

*Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to particpate in the drills;

* Evaucation time period needed; and

* Number of occupants evacuated.

* Alternate  escape routes used.

2. System will be corrected so that violation will not

happen again by;

    a. Comprehensive review of current fire drill forms

to ensure they meet all required components.

    b. Fire & Life Safety Training for Residents will be instructed within 24hrs of move-in, and reinstructed annually thereafter.

    b. All resident fire and life safety documentation will be filed and kept on-site,

    c. Facility will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction.

    d. Facility Maintenance Director will bring all fire & life safety training for residents, to Quality Improvement Meetings for review.

3. This system will be evaluated as follows:

    a. Within 24hrs of a new resident admission, &

    b. Annually thereafter,

    c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission and re-instruct residents, at least annually, on the facility's fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

A resident group interview was held on 04/16/24 at 10:45 am. Seven unsampled residents reported not being instructed on fire and life safety procedures within 24 hours of admission or being re-instructed at least annually.

On 04/17/24, Staff 2 (Regional Maintenance Director) stated that newly admitted residents were instructed on fire and life safety procedures within 72 hours of admission. He verified there was no documentation of residents being re-instructed on the procedures at least annually.

The need to ensure residents were instructed on the facility's fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, per the OFC was discussed with Staff 1 (Executive Director) and Staff 2 on 04/17/24. On 04/19/24, Staff 1 provided a written fire and life safety plan outlined the dates of when the instruction to residents would occur.

OAR 411-054-0090 (5)

Fire and Life Safety: Traning for Residents

1. Action taken to correct this rule violation includes;

    a. All residents will be instructed on General safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, and re-instructed annually. Residents who do not have the mental capability to understand

fire & life instructions and/or training, will have clear evacuation instructions in their service plans, for staff to reference.

2. Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows:

    a. All new residents will be instructed of fire &

life safety, within 24hrs of move-in, and reinstructed annually thereafter.

    b. All resident fire and life safety documentation will be filed and kept on-site,

    c. Facility Maintenance Director will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction

    d. Facility Maintenance director will bring all fire & life safety training for residents, to  Quality Improvement Meetings for review.

3. This system will be evaluated as follows:

    a. Within 24hrs of a new resident admission, &

    b. Annually thereafter,

    c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, on the facility's fire and life safety procedures according to the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records from 06/13/24 through 10/02/24 were reviewed on 10/03/24.

In an interview on 10/03/24 at 11:52 am, Staff 24 (Interim Administrator) stated that newly admitted residents were instructed on fire and life safety procedures within 24 hours of admission. She was unable to provide documentation of residents being re-instructed on the procedures at least annually.

The need to ensure residents were re- instructed on the facility's fire and life safety procedures  at least annually, per the OFC was discussed with Staff 24, Staff 25 (Wellness Nurse), and Staff 28 (Regional RN) on 10/03/24. They acknowledged the findings.

OAR 411-054-0090 (5)Fire and Life Safety: Traning for Residents

1. Actions taken to correct the rule violation are as follows;

   a. Residents were re-instructed in general safety procedures, evacuation methods, responsibilities during fire drills, and where the designated meeting places outside the building are and within the fire safe

area in the event of an actual fire were completed on 10/10/24, and 10/21/24.

   b. Unannouced fire drills scheduled for 10/23/24 and 10/24/24 on alternate shifts utilizing fire drill form that includes;

*Date and time of drill,

*Location of simulated fire origin,

*Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to particpate in the drills;

* Evaucation time period needed; and

* Number of occupants evacuated.

* Alternate  escape routes used.

    c. Evacuation chairs were ordered on 10/17/24 for each stairwell and administrator and designee were trained on fire panel test mode for drills.

2. System will be corrected so that violation will not

happen again by;

    a. Comprehensive review of current fire drill forms

were reviewed to ensure they meet all required components.

    b. Fire & Life Safety Training for all new residents will be instructed within 24hrs of move-in, and reinstructed annually thereafter. All resident fire and life safety documentation will be filed and kept on-site.

    c. Facility will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction.

    d. Facility Maintenance Director will bring all fire & life safety training for residents to Quality Improvement Meetings for review and Safety Committee Meetings for review monthly.

3. This system will be evaluated as follows:

    a. Within 24hrs of a new resident admission, &

    b. Annually thereafter,

    c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance.

4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.

Based on 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 C370, C372, C374, C420, and C422.

OAR 411-054-0105 (2-4) Inspections

and Investigation: Insp Interval

Refer to C370, C372, C374, C420, and

C422.