The findings of the re-licensure survey, conducted 04/17/23 through 04/21/23, 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 re-visit to the re-licensure survey of 04/21/23, conducted 09/05/23 through 09/07/23, 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 second revisit to the re-licensure survey of 04/21/23, conducted 03/05/24, are documented in this report. It was determined the facility was in substantial 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.

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

During the re-licensure survey, conducted 04/17/23 through 04/21/23, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number and scope of citations.

Refer to deficiencies in the report.

1. Robert Moore replaced the Administrator on record April 13th, 2023. Mr. Moore comes with many years of experience and extensive knowledge of the OAR 411 rules.  

2. Current administrator, Mr. Moore, will monitor systems daily to ensure they are in line with the Oregon administrive Rules and One Middlefiled Oaks Policies and Procedures. Allen Flores Consulting Group hired to help with support and training.

3. Quaility Assurance Systems are monitored daily with monthly follow-up meetings to discuss possible improvement areas.  

4. The Administrator (Executive Director)  

2. Resident 5 was admitted to the facility in 12/2020 with diagnoses including anxiety and multiple sclerosis.

a. Resident 5's clinical record was reviewed. The most recent evaluation located in the resident's medical chart and available to staff was completed on 12/10/20. A current evaluation was requested from Staff 3 (RCC) on 04/18/23. The quarterly evaluation provided was signed and dated on 04/19/23 or while survey was on-site.

b. Review of the resident's quarterly evaluation, dated 04/19/23, interviews with and observations of Resident 5 revealed she smoked and vaped. Resident 5's current smoking evaluation was requested on 04/19/23. Staff 3 reported the evaluation was initiated prior to survey arriving onsite, but it was not signed until 04/19/23. The most recent prior smoking evaluation was dated 07/06/22.

The need to ensure quarterly evaluations, including smoking evaluations, were completed, dated, signed and available to staff was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional documentation was provided.

3. Resident 6 was admitted to the facility in 08/2020 with diagnoses which included failure to thrive and chronic obstructive pulmonary disease.

During the acuity interview on 04/17/23, staff reported the resident had a recent weight loss.

Resident 6's clinical record, including monthly weights, was reviewed and revealed the resident had a triggered severe weight loss of 10.7% on 02/10/23 and the most recent evaluation completed and available to staff was dated 08/12/20. A current quarterly evaluation was requested from Staff 3 (RCC) on 04/20/23. She confirmed the most recent evaluation was initiated on 05/14/21; however, it was not signed or dated and there were no other evaluations with the resident's recent change of condition updates available.

Review of the resident's most recent completed evaluation, dated 08/12/20, interviews with and observations of Resident 6 were completed and revealed s/he had a recent weight loss, was to receive supplemental protein shakes twice daily, chose to eat without his/her dentures and avoided certain foods that were difficult to chew.

Resident 6's available evaluation revealed it was not reflective of his/her needs and did not include the following:

* Monthly weights;

* Food preferences and abilities; and

* Protein supplements to be given twice daily.

The need to ensure the evaluation was reviewed and updates documented following significant changes in condition, was reflective of Resident 6's current preferences and needs and was available to staff was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations were performed with updates and changes as appropriate at least quarterly for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose records were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 12/2020 with diagnoses including type 2 diabetes mellitus and chronic obstructive pulmonary disease.  

a. There was no documented evidence of any evaluation was completed after the initial evaluation in 12/2020.

b. According to a resident interview on 04/19/23 and progress notes, dated 01/24/23, s/he became an active smoker within the last six months.

A smoking evaluation had not been completed until 04/18/23 at 8:40 am (during the survey).

The need to ensure resident evaluations were performed with updates and changes as appropriate at least quarterly, was reviewed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23 at 2:45 pm. They acknowledged the findings. No further information was provided.

4. Resident 4 moved into the facility in 07/2020 with diagnoses including postherpetic polyneuropathy and mild cognitive impairment.

Resident 4's most recent evaluation, dated 03/21/23, was not dated or signed.

The need to ensure quarterly evaluations were documented, dated, and indicated who was involved in the evaluation process, was reviewed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. All residents' found out of compliance have been reviewed, updated, and corrected. All evaluations have been review to ensure within compliance. Files have also be reviewed for any possible changes of condition.

2. Care plan meetings completed weekly for the  following weeks expiring care plan/evaluations. Care plan team will consist of the RN, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Implement a move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule weekly, schedule care plan meetings, and enter information into the system. The system will be evaluated weekly to ensure within compliance.

4. Wellness Director/Delegate/ED

2. Resident 5 was admitted to the facility in 12/2020 with diagnoses including multiple sclerosis.

Resident 5's clinical record and the facility's service plan binder were reviewed on 04/18/23. Resident 5's service plan was not available to staff in either location. The resident's current service plan was requested on 04/18/23 and was received on 04/19/23.

The resident's current service plan, dated 03/22/23, was reviewed, observations were made, and interviews were conducted between 04/18/23 and 04/21/23. Resident 5's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Suprapubic catheter;

* Assistance required/requested with the catheter during showers;

* Independent versus dependent for personal hygiene;

* Edema and use of compression socks;

* Smoking status; and

* Pharmerica versus Consonus pharmacy.

The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff and were available to staff was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 08/2020 with diagnoses including failure to thrive and chronic obstructive pulmonary disease.

Resident 6's clinical record and the facility's service plan binder were reviewed on 04/18/23. On 04/20/23, Staff 3 (RCC) confirmed the service plan available to staff was dated 03/05/21 and was the most current quarterly service plan completed.

The resident's service plan, dated 03/05/21, was reviewed, observations were made, and interviews were conducted between 04/20/23 and 04/21/23. Resident 6's service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Weight loss and interventions to minimize weight loss; and

* Food preferences.

The need to ensure service plans were reflective of the identified needs of the resident, provided clear direction to staff and were updated quarterly was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, readily available to staff and provided clear directions regarding the delivery of services, and were completed quarterly for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 12/2020 with diagnoses including hemiplegia and hemiparesis, dysphagia, type 2 diabetes mellitus and chronic obstructive pulmonary disease.  

Interviews with the resident and staff, and review of the most recent service plan dated 05/27/21, revealed Resident 3's service plan was not completed quarterly, was not reflective of the current needs, and lacked clear instructions to staff in the following areas:

* Grooming;

* Bathing/showering;

* Dietary and nutrition management;

* Mobility needs;

* Smoking;

* Skin integrity; and

* Fall risk.

On 04/18/23, Staff 3 (RCC) was requested to provide any service plan for Resident 3 dated more recently than 05/27/21. Staff 3 stated updated service plans were started on 12/11/22 and 03/10/23 in the facility electronic records system but not completed.

The need to ensure the service plan reflected the resident's current needs, and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23 at 11:15 am. They acknowledged the findings.

4. Resident 1 moved into the facility in 10/2009 with diagnoses including multiple sclerosis and major depressive disorder.

a. A review on 04/18/23 showed Resident 1's service plan was not in the service plan binder available to staff. Staff 3 (RCC) stated she did not know why it was not in the binder. Staff 3 printed the service plan and placed it in the binder on 04/18/23.

b. The current service plan and MAR did not provide clear instruction for staff to follow evidenced by: Resident 1's service plan instructed, "Staff are to wipe the catheter from the insertion site toward the bag with a washcloth and warm soapy water." Resident 1's MAR instructed, " ...wiping catheter from insertion site toward the bag with an alcohol swab ..."

Staff 8 (Care Partner) stated in an interview on 04/19/23 she cleans the catheter with warm soapy water. Staff 7 (MT) stated in an interview on 04/20/23 she cleans the catheter with an alcohol swab.

5. Resident 4 moved into the facility in 07/2020 with diagnoses including postherpetic polyneuropathy and mild cognitive impairment.

Resident's 4's service plan, available to staff in the service plan binder, had a documented Last Service Plan Review Completed date of 11/10/22.

The need to ensure service plans were available to staff, provided clear instructions to staff, and were completed following quarterly evaluations was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All evaluations out of compliance are reviewed and are in compliance.  All other files (charts) have been reviewed and in compliance. Signatures of the care planning team are documented.

2. Care plan meetings completed weekly for the  following weeks expiring care plan/evaluations. Care plan team will consist of the RN, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Implement a move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule weekly, schedule care plan meetings, and enter information into the system. The system will be evaluated weekly to ensure within compliance.

4. Wellness Director/Delegate/ED

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, a licensed nurse if the resident shall need or is receiving nursing services, and at least one other staff person who was familiar with or provided services to the resident, for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose Service Planning Teams were reviewed.  Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 5's most recent service plans were reviewed during the survey. Each service plan lacked documented evidence it was developed and reviewed by the resident and other required members of his/her Service Planning Team.

The need to ensure service plans were developed with a Service Planning Team was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All evaluations out of compliance are reviewed and are in compliance.  All other resident files (charts) have beed reviewed and are in compliance. Signatures of the care planning team are documented.

2. Care plan meetings completed weekly for the  following weeks expiring care plan/evaluations. Care plan team will consist of the RN, ED, direct care staff, family, and the resident, as able. Training of the clinical team regarding the move in process, evaluations requirements, and significant changes. Implement a move-in checklist and signifcant change communication form.

3. Wellness Director or delegate will review evaluation schedule weekly, schedule care plan meetings, and enter information into the system. The system will be evaluated weekly to ensure within compliance.

4. Wellness Director/Delegate/ED

3. Resident 5 was admitted to the facility in 12/2020 with diagnoses including multiple sclerosis, lupus, fibromyalgia and anxiety.

Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 03/23/23, and progress notes dated 01/22/23 through 04/10/23 were reviewed.

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

* 01/26/23 - Missed two scheduled doses of oxycodone/acetaminophen;

* 01/28/23 - Lupus exacerbation;

* 03/30/23 - New scheduled prednisone prescription; and

* 03/30/23 - New PRN benzonatate 100mg prescription.

b. The following short-term change of condition lacked documentation of progress, at least weekly, through resolution:

* 01/19/23 - Bruise resulting from injury fall.

The need to ensure short-term changes of condition had actions or interventions determined and documented in the resident record, and communicated to staff on all shifts and progress was noted, at least weekly, until resolution was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, referred to the nurse as appropriate, actions or interventions were determined and communicated with staff, and changes were monitored through resolution, with progress noted weekly, for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 5) reviewed with changes of condition. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 08/2022 with diagnoses including atrial fibrillation.

The resident's clinical record, including progress notes, dated 01/20/23 through 04/16/23, temporary service plans (TSPs) and the current service plan, dated 04/13/23, were reviewed. The following changes of condition were identified:

Resident 2 experienced four falls between 02/14/23 and 04/16/23. Progress notes documented monitoring for pain and changes via alert charting following each fall. However, there was no documented evidence fall interventions were identified or implemented and monitored for effectiveness. The service plan did not include any fall interventions for staff to follow.

During an interview on 04/18/23 with Staff 3 (RCC), documentation related to fall investigations and interventions were requested. No documentation was provided.

The need to monitor changes of condition, determine and review interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23. No additional information was provided.

2. Resident 3 was moved into the facility in 12/2020 and had diagnoses including type II diabetes and kidney failure. Resident 3 had multiple skin conditions requiring monitoring, including the following:

* 01/17/23 Rash to abdominal folds and open areas to gluteal folds;

* 01/30/23 Right heel cracked skin that was further identified as a diabetic ulcer on 03/01/23; and

* 02/22/23 Swollen hands.

The skin injuries represented short-term changes of condition. The injuries were identified and documented in the alert monitoring charting notes by medication technicians.

While the alert monitoring of the skin injuries noted the status of the skin conditions, there was no documented evidence interventions were developed, if needed, and the interventions were being monitored for effectiveness. In addition, direct care staff documented the resident would frequently refuse to allow routine checks of the skin conditions. The resident remained on "alert" for the conditions for several months with no documentation the conditions had resolved.

The need to monitor changes of condition, determine and review interventions for effectiveness was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23. No additional information was provided.

4. Resident 1 moved into the facility in 10/2009 with diagnoses including multiple sclerosis and major depressive disorder.

The resident's clinical record, including weekly weights obtained between 01/03/23 and 04/18/23, was reviewed. The following weights were documented:

* 01/03/23 - 213 pounds;

* 01/10/23 - 215 pounds;

* 02/07/23 - 216 pounds;

* 02/14/23 - 205.5 pounds;

* 03/14/23 - 205.5 pounds;

* 03/21/23 - 202.5 pounds;

* 03/28/23 - 200 pounds;

* 04/11/23 - 203.5 pounds;

* 04/18/23 - 200.9 pounds; and

* 04/20/23 - 205 pounds (taken upon request of surveyor).

Between 01/10/23 and 02/14/23, Resident 1 lost 9.5 pounds or 4.4% body weight in one month, and the resident continued to lose weight between 02/14/23 and 04/18/23.

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident's change of condition, or monitored and documented on the resident's progress at least weekly until the condition was determined to be resolved.

5. Resident 4 moved into the facility in 07/2020 with diagnoses including postherpetic polyneuropathy, type 2 diabetes mellitus, and edema.

On 03/30/23, a progress note documented Resident 4's ankles were swollen "a lot more than normal".

There was no documented evidence the facility determined and documented what actions or interventions were needed for the resident's change of condition, or monitored and documented on the resident's progress at least weekly until the condition was determined to be resolved.

The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. Those residents identified as having a change of condition and out of compliance have been assessed by the RN. Needed interventions put in place. Changes of conditions evaluated, have been documented and communicated with the family and resident's physician and staff.

2. Staff training to identify changes of condition (COC) and reporting expectations using the Significant Change form implemented for staff to communicate with the nursing department (24 hrs. a day). Staff reporting poilcy reviewed with staff as well as documentation expectations. Nursing will assess the reported changes, develop a COC new care plan, reflecting the change fo care needs. Staff reviewes changes as implemented and sign off knowledge. Nursing will monitor change in conditions and review interventions for effectiveness.  

3. Daily monitoring of the resident chart notes and report forms to identify possible changes in condition. The new implemented Significant Change form are reviewed daily with follow up evaluation. Weekly written chart note of the progress of implemented interventions. Alert charting 3x daily also reviewed.

4. Wellness Director/Delegtate/ED  

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated including resident specific actions or interventions determined, communicated to staff on each shift and monitored weekly through resolution for 1 of 2 sampled residents (# 7) reviewed with weight loss. Resident 7 continued to experience further weight loss. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 03/2020 with diagnoses including bi-polar disorder and heart disease.

The resident's 08/04/23 progress note identified Resident 7 experienced a significant weight loss upon returning to the facility from a hospitalization.

The resident's clinical record, including weekly weights obtained between 04/14/23 and 09/05/23 were reviewed. The following weights were documented:

* 04/14/23  - 184 pounds;

* 06/14/23  - 181 pounds;

* 08/04/23  - 164 pounds; and

* 09/05/23  - 152.5 pounds.

Between 06/14/23 and 08/04/23, Resident 7 lost 17 pounds or 9.39% body weight in approximately one month resulting in a severe weight loss.  

There was no documented evidence the facility evaluated the resident, determined actions or interventions needed and communicated to staff or monitored the resident weekly through resolution.

Between 08/04/23 and 09/05/23, Resident 7 lost an additional 12.5 pounds or 7.57% body weight resulting in another severe weight loss. The facility evaluated the resident, determined what actions or interventions were needed and communicated to staff.

Resident 7 was observed to eat independently at breakfast on 09/05/23 and ate approximately 50% of his/her meal.

In an interview with Staff 16 (CG), they stated that since resident's return from hospital 08/04/23, s/he often required set up, cueing and at times hands on meal assistance due to increased confusion and pain.

During an interview with Staff 14 (RN) on 09/06/23, she verified the resident lost a significant amount of weight on 08/04/23 and there was no documented evidence the facility evaluated the change of condition, determined what actions or interventions were needed and communicated to staff at that time and the resident continued to lose weight.  

The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (ED), Staff 14 and Staff 10 (Director of Operations) on 09/07/23. They acknowledged the findings.

1.Changes of conditions identified, have a written plan in place and has been communicated with the family, resident's physicians, and staff. Plan developed and communicated to reduce reoccurrence.

2. Staff training to identify changes of condition (COC), including weight loss/gain, and reporting expectations using the Significant Change form implemented for staff to communicate with the nursing department (24 hrs. a day). Nursing will assess the reported changes, develop a COC new care plan, reflecting the change fo care needs. Staff reviewes changes as implemented and sign off acknowledge. When the community RN is not available (vacation/sick), the RN at the OneLife community in Eugene will assist with all COC and nursing needs while MFO RN is away.   

3. The new implemented Significant Change form are reviewed daily with follow up evaluation. Weekly written chart note of the progress of implemented interventions. Alert charting 3x daily also reviewed. Weight Committee reviews and developes plan for significant changes in weight.

4. Wellness Director/Delegtate/ED  

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and included documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#6) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2020 with diagnoses including failure to thrive and chronic obstructive pulmonary disease.

Resident 6's weight records were reviewed and revealed the following:

* 08/01/22 - 149.5 pounds;

* 11/15/22 - 142 pounds;

* 02/10/23 - 133.5 pounds;

* 03/10/23 - 133 pounds;

* 04/10/23 - 133 pounds; and

* 04/21/23 - 133.5 pounds (taken during the re-licensure survey).

From 08/01/22 to 02/10/23, Resident 6 had a weight loss of 16 pounds or 10.70% of his/her body weight in six months. This change in weight was considered a severe loss and indicated a significant change of condition which required an RN assessment.

On 04/21/23 at 12:00 pm, an RN assessment for the significant change of condition was requested. The facility RN was unavailable for interview during the survey, but Staff 1 (ED) confirmed there was no RN assessment completed for Resident 6's severe weight loss.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional documentation was provided.

1. The resident identified as having a change in condition and out of compliance has been RN assessed for change in condition (COC), and interventions put in place. The care plan team of RN, caregiver, family, and resident, participated in developing the new care plan. Signatures of the care planning team are documented.  

2. The remaining resident charts and documented notes are reviewed for possible significant changes in condition as compared to current care plan. RN will assess all possible changes and put interventions in place as assisted with the care plan team including the resident. RN completed staff education for proper communication of concerns, possible COC, incidents, and changes in resident care needs. Training included the newly implemented Significant Change forms for RN communicaiton. The care planning team works together to address concerns, develops a plan, and put interventions in place. New Change of condition care plans implemented and are communicated with staff, review and signed. Staff are held accountable to follow.

3. Daily review of chart notes, Change in Condition form, and IDT meeting follow-up will be completed by the community nursing department and ED.

4. Wellness Director/Delegate/ED

Based on interview and record review, it was determined the facility failed to conduct an RN assessment which including findings, resident status and interventions made as a result for 1 of 2 sampled residents (#7) who experienced a significant change of condition related to weight loss.  Resident 7 continued to lose weight.  This is a repeat citation.  Findings include, but are not limited to:

Resident 7 was admitted to the facility in March 2022 with diagnoses including bi-polar disorder and heart failure.

Weight documentation reviewed between 04/14/23 and 09/05/23 noted the following:

* 04/14/23  - 184 pounds;

* 06/14/23  - 181 pounds;

* 08/04/23  -  164 pounds; and

* 09/05/23  - 152.5 pounds.

Between 06/14/23 and 08/04/23, Resident 7 lost 17 pounds or 9.39% body weight in approximately one month resulting in a severe weight loss and a significant change of condition.

There was no documented evidence the facility RN conducted an assessment which included findings, resident status and interventions made as a result.  

Between 08/04/23 and 09/05/23, Resident 7 lost an additional 12.5 pounds or 7.57% body weight resulting in another severe weight loss and a subsequent significant change of condition.

Observations of the resident between 09/05/23 and 09/07/23 showed the resident was able to feed himself/herself once provided food. The resident did not seek out or ask for food items during the survey observations but would accept items when staff offered.

There was no documented evidence an RN significant change of condition was completed at the time of the weight loss noted 08/04/23.

The need for an RN assessment related to the significant change of condition was discussed with Staff 1 (ED), Staff 10 (Director of Operations) and Staff 14 (RN) on 09/07/23. They acknowledged the findings. On 09/06/23, Staff 14 completed a significant change of condition due to severe weight loss for Resident 7.

1. The resident(s) identified as having a change in condition and out of compliance, has been RN assessed for change in condition (COC). Correction plan developed to monitor and correct the changes.

2. Staff training completed for proper communication of concerns, possible COC, incidents, significant weight changes, and changes in resident care needs. Training included the Significant Change forms for RN communicaiton. The care planning team works together to address concerns, develop a plan, and put interventions in place. Staff are held accountable to follow COC's and care plans. When the community RN is not available (vacation/sick), the RN at the OneLife community in Eugene will assist with all COC and nursing needs while MFO RN is away.     

3. Daily review of chart notes, Change in Condition form, and IDT meeting follow-up will be completed by the community nursing department and ED. Weight Committee developed to monitor weight changes to discuss and put in place interventions.   

4. Wellness Director/Delegate/ED

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure documentation of visits was maintained in the facility, and ensure staff were informed of new interventions for 1 of 3 sampled residents (#1) who received services from an outside provider. Findings include, but are not limited to:

Resident 1 moved into the facility in 10/2009 with diagnoses including multiple sclerosis and major depressive disorder.

Resident 1 was identified during the acuity interview on 04/17/23 as receiving HH for catheter care.

* On 04/18/23 Staff 7 (MT) reported the HH RN had been to see Resident 1 on 04/13/23. Review of records showed the last HH note retained in the resident's record was 03/06/23.

* A HH RN note on 03/06/23 stated, "Please make sure patient suprapubic dressing is done daily." The facility lacked documented evidence the recommendations were followed.

The need to have a system for coordinating on-site services with outside providers was discussed with Staff 3 (RCC) on 04/18/23 and with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings. No further information was provided.

1. All residents' found out of compliance have been reviewed, updated, and corrected, using the care plan team of RN, caregiver, family, and resident. All other resident charts (files) have been reviewed and are in compliance. Signatures of the care planning team are documented.

2. Communicate with all outside providers that it is required to complete the "Outside Providers form" after each visit. New process implemented: outsident providers are handed the Outside Providers form while checking in at the front desk with a reminder that it must be returned upon exit of the building. The front desk personnel with start the required documentation process and will forward to the nursing department as soon as possible. After hours visits by outside providers will be instructed to return the form to the Med-tech on duty. This new process communicated with staff. Care plans identify outside providers and care objectives.  

3. Nursing dept. evaluates process weekly. R

4. Wellness Director/Delegate/ED

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

During the relicensure survey, conducted 04/17/23 through 04/21/23, administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:

* C 303: Systems: Medication and Treatment Orders;

* C 304: Systems: Medication and Treatment Review;

* C 305: Systems: Resident Right to Refuse;

* C 310: Systems: Medication Administration; and

* C 325: Systems: Self Administration of Medication.

Failure to ensure a safe medication system and lack of adequate professional oversight was discussed with Staff 1 (ED), Staff 2 (ED) and Staff 14 (RN) on 04/21/23. They acknowledged the findings.

1. All residents' chart (MARS) found out of compliance have been reviewed and needed corrections or needed clarifications have been sent to prescribing physician. All other MARs have reviewed also and are in complaince. Returned documention by physician will be implemented and documented. New Quarterly Physician's orders sent to prescriber for review and approval.

2. Quarterly Physician Orders are sent at minimun each quarter, to the prescribed for review and approval. Quarterly Orders are sent the contracted pharmacy and updated/new orders are placed into the MAR system. Staff completes second check to ensure the MAR is correct. Additionally, the pharmacy completes quarterly audits of the MAR and orders. All Med-techs will re-complete Medication Pass training.

3. Nursing will monitor compliance weekly x3, monthly, quarterly. Nursing will observe medication pass of all Med-techs each quarter.

4. Wellness Director/ED follow up

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 and treatments the facility was responsible to administer for 5 of 6 sampled residents (#s 1, 3, 4, 5 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 12/2020 with diagnoses including multiple sclerosis.

Resident 5's MAR/TAR, dated 04/01/23 through 04/17/23 and corresponding progress notes and prescriber orders were reviewed and revealed the following:

a. Resident 5 was receiving the following medication and treatment:

* Rosuvastatin 5 mg - one tablet by mouth every evening for cholesterol; and

* Wound Care - clean area and apply split sponge or gauze around site for irritation/sanitation of suprapubic catheter.

The medication and treatment orders were requested on 04/18/23, 04/19/23 and 04/21/23. The facility had no documentation of signed physician orders for the catheter treatment or the cholesterol medication.

b. The resident had a physician's order for the facility to administer oxybutynin 7.5 mg by mouth four times a day for bladder spasms. The resident's MAR revealed a blank on 04/03/23 at 2:00 pm.

On 04/19/23 at 8:32 am, the surveyor and Staff 6 (MT) observed and checked the MAR/TAR and medication supply. Staff 6 was unable to verify if the above order had been followed.

The need to ensure medications were carried out as prescribed and written physician orders were documented in the resident's facility record was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional information was provided.

2. Resident 6 was admitted to the facility in 08/2020 with diagnoses including failure to thrive.

During the acuity interview on 04/17/23, Resident 6 was identified to have had a recent weight loss.

Resident 6's MAR/TAR dated 04/01/23 through 04/17/23, monthly weights and prescriber orders were reviewed. Interviews with and observations of the resident were completed and revealed the following:

a. Resident 6 had a physician's order, dated 07/14/22, to complete a weight check in the evening every 30 days for healthcare monitoring. The following weights were recorded:

* 04/10/23 - 133 pounds;

* 03/10/23 - 133 pounds;

* 02/10/23 - 133.5 pounds;

* 11/15/22 - 142 pounds;

* 08/01/22 - 149.5 pounds; and

* 07/01/22 - 149 pounds.

In an interview with Staff 1 (ED) and Staff 2 (ED) on 04/21/23, it was confirmed weights had not been obtained in 09/2022, 10/2022 or 01/2023 as ordered for the resident.

b. Resident 6 had a physician's order dated 03/02/23 to "increase protein supplement shake to twice a day and ensure it [was] given daily as directed due to 10 pound weight loss in six months and failure to thrive."

On 04/20/23 at 12:31 pm, two chocolate shakes were observed near the resident's chair. Resident 6 stated, "today is the first day I've gotten these [lifted health shakes] at this time of day. I get one a night four nights a week." Resident 6 continued, "My daughter sent Ensure. I do like the chocolate healthshakes. Ensure is better. I drink two a day. My daughter is continually sending them. I'd leave my daughter alone if I could get the health shakes everyday."

On 04/21/23 at 9:15 am, Resident 6 reported s/he had not received a health shake that morning and there were no visible health shakes in the resident's room. The resident's 04/21/23 MAR was requested and reviewed and indicated the health shake was provided at 8:00 am by a MT.

At approximately 9:30 am on 04/21/23, Staff 13 (Cook) confirmed all health shakes were stored in the kitchen for the assisted living residents and no caregivers had come to the kitchen for health shakes that morning.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional information was provided.

3. Resident 3 moved into the facility in 12/2020 with diagnoses including hypertension and type II diabetes mellitus.  

Review of Resident 3's current physician orders and MAR from 04/01/23-04/17/23 revealed the following:

* Blood sugar checks (CBGs) were ordered four times daily (for diabetes). The physician was to be notified of any CBG below 80 or above 350. There was no documented evidence the facility notified the physician of blood sugars above 350 on twelve occasions;

* Carvedilol 12.5mg (for hypertension) was ordered to be held for pulse less than 45. There was no documented evidence the pulse was taken on 16 occasions when the medication was administered; and

* Acetaminophen 325mg (for pain) was ordered to be administered every six hours as needed for pain. Medication was administered within 4.5 hours on 04/07/23.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23 at 11:15 am. They acknowledged the findings. No further information was provided.

4. Resident 1 moved into the facility in 10/2009 with diagnoses including multiple sclerosis and major depressive disorder.

Resident 1's MAR, dated 04/01/23 through 04/17/23, and prescriber orders were reviewed. The following deficiencies were identified:

a. Resident 1 had orders for weekly weights. Between 01/03/23 and 04/17/23 weights were not taken seven out of 16 weeks.

b. Resident 1 had orders for notifying PCP of weight loss/gain of three pounds or more in two weeks or one month. The resident experienced a weight loss/gain of three pounds or more in two weeks on the following dates:

* 02/07/23;

* 02/14/23;

* 03/14/23;

* 03/21/23;

* 03/28/23;

* 04/11/23.

The facility lacked documentation that the PCP had been notified of these three pounds or more weight fluctuations.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional information was provided.

1. All residents' chart (MARS) found out of compliance have been reviewed and needed clarifications have been sent to prescribing physician. Remaining files (charts) have been reviewed and ar ein compliance. Returned documention by physician will be implemented and documented. Orders are sent to the contract pharmacy for MAR input.

2. Each resident chart and MAR are reviewed to  confirm all needed orders are correct and in place. Resident presribed orders are verified, sent to the pharmacy for review and MAR imput. Second checks against original order, are completed by staff. Quarterly review by pharmacy and physican will ensure proper orders are in place and correct.  

3. WD/designee will review for compliance weekly x3 months then monthly. WD/designee will complete med pass observation of each Med-tech each quarter.

4. Wellness Director/ED follow up   

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered by the facility to residents at least every 90 days for 4 of 5 residents (#s 1, 3, 4 and 5) whose medication and treatment orders were reviewed. Findings include, but are not limited to:

Residents 1, 3, 4 and 5's records were reviewed and showed a lack of documented review by a registered pharmacist or registered nurse every 90 days.

The need to ensure a registered pharmacist or registered nurse reviewed medications and treatments administered by the facility to residents at least every 90 days was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23 at 11:15 am. They acknowledged the findings. No further information was provided.

1. Quarterly/current order review completed by pharmacy. Changes to current orders have been corrected.

2. Each resident chart and MAR are reviewed to  confirm all needed orders are correct and in place. Resident presribed orders are verified, sent to the pharmacy for review and MAR imput. Second checks against original order, are completed by staff. Quarterly review by pharmacy and physican will ensure proper orders are in place and correct.  

3. Wellness Director/designee reviews quarterly pharmacy review and Quarterly Physician orders to confirm within compliance.

4. Wellness Director and ED as follow up

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 1 of 1 sampled resident (#3) with multiple medication refusals. Findings include, but are not limited to:

Resident 3's MARs from 04/01/23 through 04/17/23 and corresponding progress notes were reviewed. The resident's records showed the following medication and treatment refusals:

* Buspirone 30mg (for panic disorder) on 04/06/23;

* Foot soak with Epsom salt (for foot health) on 13 occasions;

* Eucerin cream 454gm (for skin health) on 13 occasions;

* Melatonin 5mg (for insomnia) on 04/06/23;

* Mineral Oil Heavy (for skin care) on ten occasions;

* Mirtazapine 7.5mg (for panic disorder) on 04/06/23;

* Miralax 3350 NF (for constipation) on nine occasions; and

* Senna 8.6mg (for constipation) on 04/06/23.

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

The need to ensure the facility notified the physician or other practitioner of medication and treatment refusals was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23 at 2:45 pm. They acknowledged the findings. No further information was provided.

1. All residents' found out of compliance have been reviewed for undocumented refusals. Remaining resident charts have been reviewed and are in compliance. Prescribing physicians have been notified of refusals and non-compliance as prescribed. The follow up has been documented.

2. The re-training of medication administration system will be completed by all Med-techs. Resident chart notes are monitored for refusals of prescribed medications and treatments to ensure the prescribing physician has been notified.

3. Wellness Director/designee monitors daily chart notes and incident reports to ensure the required reporting has been completed.

4. Wellness Director/ED followup    

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications that were ordered by a legally recognized provider and administered by the facility, for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 07/2020 with diagnoses including postherpetic polyneuropathy.

Resident 4's 04/01/23 through 04/17/23 MAR was reviewed and identified the following:

On 04/04/23 Bactrim (for infection) was marked both as given by the facility and self-administered. In an interview on 04/21/23, Resident 4 confirmed the medication was self-administered per the provider order.

The need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

4. Resident 5 was admitted to the facility in 12/2020 with diagnoses including multiple sclerosis and juvenile rheumatoid arthritis.

Resident 5's MAR dated 04/01/23 through 04/17/23 was reviewed and revealed blanks for the following medications:

* Baclofen (muscle relaxer) on 04/03/23 at 2:00 pm;

* Gabapentin (for pain) on 04/03/23 at 2:00 pm; and

* Oxycodone/acetaminophen (for pain) on 04/03/23 at 2:00 pm.

On 04/19/23 at 8:23 am, the surveyor and Staff 6 (MT) reviewed the MAR and checked the medication cart. Staff 6 verified the medications had been given, but staff failed to document on the MAR.

The need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

3. Resident 3 moved into the facility in 12/2020 with diagnoses including hypertension and chronic pain.  

Resident 3's MARs from 04/01/23 through 04/17/23 and physician orders were reviewed, and revealed the following:

a. The following medications had blanks on the MAR:

* Anastrozole 1mg on 04/13/23;

* Hydrocodone/APAP 7.5/325mg on 04/03/23 at 2:00 pm; and

* Hydrocodone/APAP 7.5/325mg on 04/03/23 through 04/06/23, 04/09/23, 04/14/23, and 04/15/23 prn at 8:00 pm.

Observations, record review and interviews with Staff 15 (MT) on 04/19/23 at 5:45 pm and Staff 7 (MT) on 04/20/23 at 10:10 am revealed the anastrazole had not been received from the pharmacy. A review of narcotics tracking logs showed the hydrocodone doses listed above had been documented as administered on the logs, but not marked on the MAR.

b. The following medications were marked as administered but not given:

* Anastrozole 1mg on 04/02/23, 04/12/23 and 04/14/23; and

* Lisinopril 10mg on 04/05/23, 04/06/23 and 04/07/23.

In an interview and observations performed at the medication cart on 04/20/23, Staff 7 (MT) confirmed the anastrazole had not yet been received from the pharmacy. The lisinopril had been received on 04/12/23 and the first pill had been "popped" from the blister pack on 04/13/23.

c. The following medications lacked specific instructions on the location to apply the treatment:

* Eucerin cream 454gm (for skin health);

* Foot soak with Epsom salt (for foot health); and

* Mineral Oil Heavy (for skin care).

d. The foot soak with Epsom salt had been discontinued on 03/08/23 but remained on the MAR with no indication it had been discontinued.

The need to ensure MARs were accurate and contained medication-specific instructions was reviewed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23. They acknowledged the findings. No further information was provided.

2. Resident 2 moved into the facility in 08/2023 with diagnoses including atrial fibrillation and was receiving Hospice services.

Resident 2's physician orders and 04/01/23 through 04/17/23 MARs were reviewed and revealed the following:

The following medications lacked resident specific parameters or instructions to direct staff which PRN medication should be administered and in what order:

* Bisacodyl, Polyethylene Glycol and Senna for constipation; and

* Albuterol and Lorazepam for shortness of breath.

In an interview on 04/20/23, Staff 2 (ED) acknowledged the lack of parameters and clear instructions to staff for PRN medications.

The need to ensure an accurate MAR that included resident specific parameters and clear instructions for staff when more than one PRN medication was prescribed for the same condition was reviewed with Staff 1 (ED) and Staff 2 on 04/21/23. They acknowledged the findings.

1. All residents' orders found out of compliance have been reviewed, updated, and corrected. Residents that were identified to be self administer have been evaluated and orders sent for physican approval. All remaining resident charts reviewed and are in compliance. Documented requests for parameters sent to prescribing physcian for those resident orders missing the required parameters.

2. Review all orders for proper parameters are prescribed for compliant administration. Review all new orders to ensure and request parameters as needed. All self adminstration residents will have a quarterly Self Medication Assessment completed. Care plans and eMARs, will reflect self medicatiuon approval.

3. New orders reviewed and parameters are confirmed to be in placed as soon as possible. Self admin order approvals are monitored quarterly.  

4.Wellness Director/designee    

Based on observation, interview, and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 8 and 9) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 01/2021 with diagnoses including edema.

The resident's current physician's orders and the MAR dated 08/01/23 through 09/07/23 were reviewed and revealed the following:

* Resident 8 had a physician's order dated 05/19/23 for compression wraps to be applied in the morning and removed at night for edema; and

* The MAR indicated the resident's compression wraps were donned by staff daily from 08/01/23 - 09/07/23 except on three occasions when the resident refused, or the MAR was blank. The MAR also indicated the resident's compression wraps were doffed by staff daily from 08/01/23 - 09/06/23.

On 09/05/23, Resident 8 was observed without his/her compression wraps at 1:10 pm. During an interview on 09/06/23 at 12:00 pm, Resident 8 was not wearing his/her wraps and reported s/he had refused to wear them since the onset of lower extremity wounds on 07/31/23.

The need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 14 (RN) on 09/07/23 at 1:02 pm. They acknowledged the findings.

2. Resident 9 was admitted to the facility in 01/2023 with diagnoses including dementia and mood disturbance.

A review of Resident 9's 08/01/23 through 9/05/23 MAR identified the following treatments lacked resident-specific parameters:

* Baza Protect cream 12% - apply topically three times daily and as needed to affected area on buttocks; and

* Petroleum Jelly 13 oz - apply to affected area on coccyx twice daily to help prevent further irritation.

Staff 8 (CG) reported on 09/06/23 that s/he applied Baza Protect cream to entire area of buttocks and coccyx and then applied the petroleum jelly on top of the Baza Protect cream over the entire buttocks and coccyx.

The need to ensure MARS included written parameters for medications and treatments that were so specific unlicensed caregivers were not required to use discretion, was discussed with Staff 1 (ED) and Staff 14 (RN) on 09/08/23. They acknowledged the findings.

1. Resident MAR's reviewed and confirmed accuracy as prescribed. Contracted pharmacy also confirmed. Family and physicians notified of any missed medications.  

2. Review all orders for proper parameters are prescribed for compliant administration. Review all new orders to ensure and request parameters as needed. Med staff are required to complete the Medication Administration Training course and are held accountable for an accurate admistration of prescribed medications.

3. New orders reviewed and parameters are confirmed to be in placed as soon as possible. Staff utilize the 3 check system for all new orders. Medications orders are reviewed and confirmed quarterly. Med pass exception report reviewed and concerns are addressed, daily.

4.Wellness Director/designee

Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated for safety and ensure physician's orders were in place for the self-administration of prescription medications for 2 of 2 sampled residents (#s 4 and 5) who self-administered medications. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 12/2020 with diagnoses including chronic obstructive pulmonary disease.

Review of Resident 5's physician's orders and MAR, dated 04/01/23 through 04/17/23, revealed the resident self-administered some of his/her PRN medications.

a. During an interview on 04/19/23,  Resident 5 stated s/he self-administered two medications. The medications were observed and determined to not have corresponding orders to self-administer:

* Albuterol inhaler 90 mcg (for wheezing); and

* Mupirocin 2% ointment (for wound healing).

Orders for the two prescription medications to be self-administered were requested on 04/18/23 and 04/19/23. The facility was unable to provide the requested physician's orders.

b. The resident's quarterly self-administration evaluation was requested and received on 04/19/23. Staff 3 (RCC) confirmed she had initiated the evaluation on 04/18/23 which was during the re-licensure survey. On 04/21/23 at 11:47 am, Staff 1 (ED) confirmed there were no previous evaluations to support the resident was safe to self-administer medications.  

The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 and Staff 2 (ED) on 04/21/23. They acknowledged the findings, and no additional information was provided.

2. Resident 4 moved into the facility in 07/2020 with diagnoses including postherepetic polyneuropahty. During the acuity interview the resident was identified as administering some of his/her own medications.

Resident 4's MAR, dated 04/01/23 through 04/17/23, prescriber orders, and a self-medication evaluation was reviewed. The following deficiencies were identified:

a. The most recent self-medication evaluation was not signed or dated.

b. Resident 4 had an order for niacin 500 mg tr tab (for heart health). The MAR indicated this was self-administered. There was no documented evidence of an order for self-administration of this medication.

The need to have a completed self-medication evaluation upon move-in and at least quarterly for all residents who administered their own medications, and to have physician's orders for prescription self-administered medications was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. All residents' orders found out of compliance have been reviewed, updated, and corrected. Residents that were identified to be self administer have been evaluated and orders sent for physican approval. The remaining resident charts have been reviewed and are in compliance. Self Medication Administration evaluation completed as needed. Physician orders are sent to physician, documented, and placed in eMAR.

2. Self medication requests will receive a Self Medication Administration evaluation. Physician approval requests sent and documented  All self adminstration residents will have a quarterly Self Medication evaluation completed. Care plans and eMARs, will reflect self medicatiuon approval.

3. Self Medication orders are second checked upon prescribed eMar entry. Self admin order approvals are monitored quarterly.  

4.Wellness Director/designee    

Based on interview and record review it was determined the facility failed to ensure an Acuity Based Staffing Tool (ABST) assessment was completed for each resident before move in, and was reviewed and amended for each resident whenever there was a significant change of condition or at least quarterly. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 08/2022. Review of the ABST record for Resident 2 indicated the assessment had been initially created on 04/18/23.

2. Review of the facility's online ABST indicated Residents 1, 3, 4, 5, and 6's ABST had not been updated quarterly.

The need to implement an ABST based on updated information and included all residents was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/21/23. They acknowledged the findings.

1. Ensure all care plans are up to date and correct. Input ADL cares into the ABST program.

2. Care plans will be kept up to date and correct. Changes in care, change in condition (from baseline), new resident admissions, and Dc'ed residents will be entered into the ABST program. Maintain proper staff according to the staffing tool.  

3. Minimum weekly reviews of the ABST program and when there is any new resident admissions, change in care, change in condition (baseline), and Dc'ed residents.

4. Nursing department manages the ABST program and it's contents. The Executive Director, monitors the program for correctness.

Based on interview and record review, it was determined facility failed to ensure direct care staff completed and documented 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 setting, including six hours of training on dementia care, for 2 of 2 long-term staff (#s 6 and 11) whose training records were reviewed. Findings include, but are not limited to:

a. Staff 6 (MT), hired 10/2016, failed to have documented evidence of completing 12 hours of required in-service training, including six hours of training on dementia care, between 10/2021 and 10/2022.

b. Staff 11 (Care Partner/MT), hired 08/2020, failed to have documented evidence of completing 12 hours of required in-service training, including six hours of training on dementia care, between 08/2021 and 08/2022.

During an interview on 04/20/23, Staff 4 (Business Office Manager) was provided information on annual training requirements for staff and acknowledged the facility did not currently have a tracking system for annual staff training.

The need to ensure staff completed and documented the required annual in-service training was reviewed with Staff 1 (ED) and Staff 4 on 04/20/23. They acknowledged the findings. No further information was provided.

1. All employee files are audited to ensure each employee has 12 hours of approved training including six (6) hours of Dementia training.

2. New employee checklist form completed at hire, meeting the ODHS requirements for onboarding. Monthly review of employee files to assign coursework, including six (6) hours of Dementia training and Infection Control, using Oregon Care Partners/Relias, are completed on or before the employee anniversary date of hire.

3.New employee files are monitored at 30 days for the required training during onboarding. Employee files are monitored monthly to track the completion of the 12 hour trainings which include 6 hours of Dementia and infection control training.

4. HR Director is responsible for ensuring that all training records for all employees are up to date and within compliance. The ED monitors compliance.   

Based on interview and record review, it was determined the facility failed to have a system in place to ensure all direct care staff completed a minimum of 12 hours of in-service training annually on topics related to the provision of care, including 6 hours of dementia training. This is a repeat citation. Findings include, but are not limited to:

In an interview on 09/06/23 Staff 4 (Business Office Manager) reported he had a spreadsheet for recording annual training. The spreadsheet was observed to be blank. Staff 4 stated he was planning on assigning online courses to staff.

Monthly staff meeting minutes from 05/2023 through 09/2023 were reviewed with Staff 4. Staff meetings which included training on topics related to provision of care did not include the time spent on training.

The need to ensure there was a system in place for ensuring all staff completed the required annual training was discussed with Staff 4 on 09/06/23 and with Staff 1 (ED) on 09/07/23. They acknowledged the findings.

1. Employee files have been reviewed and a tally of completed/outstanding tasks are compiled into the training tracker. Outstanding inservices have been assigned to those employees.  

2. Utilize the new Employee Training Tracker form to meet the ODHS requirements for onboarding and ongoing training. Monthly Training Calendar completed for all employees to review each month to identify what online training are due, inservice topics for the month, and fire drill due.

3.Employee files are monitored monthly to track the completion of the all required and scheduled trainings, inservices, and fire dirills.This will also include the annual 6 hours of Dementia and infection control training.

4. HR Director is responsible for ensuring that all training records for all employees are up to date and within compliance. The ED monitors compliance.

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

A review of fire and life safety records provided from 11/2022 through 04/2023, identified the following deficiencies:

* Lack of documented evidence fire drills were being conducted every other month. There were no drills conducted between 11/07/22 and 04/14/23; and

* Lack of documented evidence fire and life safety instruction was being provided to staff on alternate months. There was no documented evidence of staff training conducted since 12/22/22.

An interview on 04/19/23, Staff 5 (Maintenance Director) acknowledged there was a "gap" in conducting fire drills or fire and life safety instruction for staff and the facility had recently resumed doing drills.

On 04/21/23, the need to ensure fire drills and fire and life safety instruction were completed on alternate months was discussed with Staff 1 (ED). He acknowledged the findings.

1. Fire drills completed and up to date. Staff training on the fire drill process, evacuation plan, simulated fire, and documentation.

2. Bi-monthly (every 2 months) fire and evacuation drills are completed, with ED reviews to ensure complainace. Bi-monthly staff in-servicing of fire and life safety are completed on months when fire drills are not scheduled.

3. Monthly reviews of documented drills are completed by the ED and the Director of Maintenance.

4. Director of Maintenance is responsible for assigning and completing the required fire drills and evacuation as required. This includes the required in-servicing for all employees.      

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

Refer to C 270, C 280, C 310 and C 374.

Refer to above citations and Plan of Corrections.

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

During a tour of the facility on 04/17/23 at 10:50 am the following was identified:

* The area outside the enclosed dumpster space next to the MCC wing contained old furniture, appliances, a Hoyer lift, and other discarded items; and

* The interior courtyard, grounds around the perimeter of the building, and resident smoking area contained drop-offs, up to approximately four inches in depth, from the concrete pathways to the surface of the adjacent ground. The drop-offs created a potential fall hazard for residents who used these areas.

The refuse and drop-offs were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 04/17/23 at 1:00 pm, and with Staff 10 (Director of Operations) on 04/17/23 at 1:40 pm. They acknowledged the findings. No further information was provided.

1. Ground cover material brought into all "out of compliance" areas (as identified by surveyor) to fill in the drop-off potentially hazardous spots adjacent to the sidewalks. Storage areas are cleaned and organized.

2. Enviromental walk throughs completed to monitor for concrete drop-off areas, exterior rubbish, and compliance of all storage areas.

3. Monthly enviromental walk throughs, both interior and exterior.

4. Maintenance Director is responsible for proper storage of items and completing the Monthly Walk throughs of all areas to ensure compliance.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 04/17/23 at 10:50 am The following was identified:

a. Hallways and first floor:

* Handrails had exposed wood, gouges, and splinters;

* Light fixtures in main entrance to facility were dusty, covered with cobwebs, and contained dead insects;

* Three out of 14 light fixtures in main entrance were not operating;

* Doors to resident rooms 105, 106, 109, 116, 116, 119 had black wear marks and scratches;

* Paint under door handle to Room 111 had worn off, exposing raw wood;

* Wood frame surrounding elevator door was damaged, chipped, and stained;

* Corner of wall next to elevator was damaged, exposing underlying drywall;

* Lights in library/sitting area next to main entrance had two ceiling light fixtures not operating, and one light fixture with no cover; and

* Corner of wall next to water fountain was damaged, exposing underlying drywall.

b. Hallways and second floor:

* Handrails had exposed wood, gouges, and splinters;

* Wood frame surrounding elevator door was damaged, chipped, and stained;

* Wall corner at top of stairs to second floor was patched unevenly and unpainted;

* Sitting bench next to Room 222 was dirty and stained with accumulated debris;

* Walls in open medication station area were scratched and chipped, exposing underlying drywall; and

* Room 207 had frayed carpet and lifting transition piece between the kitchen and living room.

c. Laundry room first floor:

* One dryer was not operational;

* Dust and dirt accumulated behind dryers; and

* Scratches on the wall next to the washing machines.

d. Laundry room second floor:

* One washing machine was not operational;

* Cabinet under sink in hopper room had broken handle and loose hinges;

* One light fixture had a cracked cover, and three light fixture covers contained dead bugs; and

* Ceiling vent grate was covered with dust.

e. Commercial laundry room:

* Torn baseboard moulding next to commercial dryer; and

* Top surface of commercial dryer was covered with a thick layer of dust.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 04/17/23 at 1:40 pm. They acknowledged the findings. No further information was provided.

1. All identified non-compliant areas identified under C613, have been repaired, fixed, repainted, changed or replaced.

2. Maintenance enviromental task sheet developed to be completed weekly. The form is designed to evaulate each area of the interior to ensure to be in compliance, areas are clean and in repair.  

3. Weekly review of interior areas using the Enviromental Task sheet.

4. Maintenance Director completes weekly Enviromental Task sheets which is then reviewed and signed off by the Executive Director.  

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

Facility was toured on 04/17/23 at 10:50 am. Resident unit windows on the second floor opened vertically, and window sill heights were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.

The lack of a mechanism to prevent accidental falls was discussed with Staff 5 (Maintenance Director) and with Staff 10 (Director of Operations) on 04/17/23. They acknowledged the findings. No further information was provided.

1. All resident apartments on the second floor, with window sill lower than 36 inches from the floor and designed to open vertically, are placed with a mechanism to which limits how much the window could open.

2. Monthly checks of each of the second floor windows to ensure the locking mechanism is in place and functional effectively to stop the window from rinsing to far.

3. Monthly checks by the Maintenance Director with caregiver monitoring during apartment visits.

4. Maintenance Director and the Executive Director.  

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

Heaters were installed in 16 one-bedroom units where residents could come into incidental contact. A heater in one one-bedroom unit was tested by the surveyor, and the wall heater cover reached temperatures above 200 degrees Fahrenheit.

The heaters were discussed with Staff 5 (Maintenance Director), and power to the heaters was disconnected on 04/19/23 at 11:20 am to prevent excess temperature on the heaters until a long-term plan could be determined and implemented by the facility.

The need to ensure heating surfaces did not exceed 120 degrees Fahrenheit when located in areas where incidental contact could occur was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23 at 2:45 pm. They acknowledged the findings. No further information was provided.

1. The cadet heater power has been shut off to each heater with a lock out tag placed on the breaker to avoid accidential activation, on each cadet heater. Notification of the disabled cadet heaters, sent to all affected residents and their families.

2. Diabled interventions will remain in place until a permanent solution is put into place.

3. Weekly maintenance walk through are made to ensure interventions are still in place.

4. The maintenance director is responsible for monitoring and reporting all findings to the executive director.  

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

The building was toured on 04/17/23 at 10:50 am. Observations and interviews with staff confirmed the doors by which residents could exit the facility did not have a functioning alarm or other system to alert staff when residents exited the building.

The need to ensure the facility had an alarm or other acceptable system to alert staff when residents exited the facility was discussed with Staff 1 (ED) and Staff 2 (ED) on 04/20/23 at 2:45 pm. They acknowledged the findings. No further information was provided.

1. Exit door alarms have been repaired. Training completed with all employees on the Atmost call system, which includes identification of the notification, response, timeliness, monitoring, and rounding. Handheld responders inplace with back up plan.

2. New employees are trained on the Atmost alarm call (monitoring) system. Batteries required for the system will be changed on a preventive maintenance schedule. Front desk monitoring and back up notification on the call/door system to ensure staff reply quickly to calls.

3. Monthly battery changes prompted by preventive maintenance schedule. Reports are pulled to monitored for response times. Call/door alarm system tested weekly.

4. Maintenance Director with ED follow up