The findings of the re-licensure survey conducted 07/18/22 through 07/21/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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
Situations were identified where there was a failure of the facility to comply with the Department's rules that were likely to cause a resident serious harm. An immediate plan of correction to resident's health and safety was requested in the following areas:
OAR 411-054-0040: Change of Condition and Monitoring; and
OAR 411-054-0055: Systems: Medication Administration and Systems: Treatment Orders
The facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first re-visit to the re-licensure survey of 07/21/22, conducted 01/17/23 through 01/18/23, 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
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
The findings of the second re-visit to the re-licensure survey of 07/21/22, conducted 04/18/23, 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
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
The findings of the third re-visit to the re-licensure survey of 07/21/22, conducted 07/06/23, 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 observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to:
During the re-licensure survey, conducted 07/18/22 through 07/21/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.
1. Situations were identified which constituted an immediate plan of correction to residents' health and safety in the following areas:
OAR 411-054-0040: Change of Condition and Monitoring; and
OAR 411-054-0055: Systems: Medication Administration and Systems: Treatment Orders.
The facility put immediate plans of correction in place during the survey and the situations were abated.
2. Refer to deficiencies in the report.
C150
OAR 411-054-0025 (1) Facility Administration Operation
Refer to deficiencies in the report.
2. Resident 1 was admitted to the facility in 04/2018 with diagnoses including mild dementia and anxiety.
The resident's quarterly evaluation, dated 06/07/22 was reviewed and care staff were interviewed. The following inaccuracies were identified:
* Independent with all tasks related to dining;
* Understanding of the facility's fire safety process;
* Assistance needed with wrist brace(s);
* Side rail use;
* Alternative measures or interventions utilized prior to the administration of a psychotropic medication;
* Potential side effects of a psychotropic medication;
* Size of group for activity participation; and
* General skin condition.
The need for quarterly evaluations to be accurate was discussed with Staff 1 (ED) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
The resident's quarterly evaluation, dated 07/10/22 was reviewed and Resident 2 was interviewed. The following inaccuracies were identified:
* Self administering of an inhaler;
* Understanding the facility's fire safety process;
* Current and past treatments for pain; and
* General skin condition.
The need for quarterly evaluations to be accurate was discussed with Staff 1 (ED) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) and failed to ensure quarterly evaluations were reflective for 2 of 2 sampled residents (#s 1 and 2) whose evaluations were reviewed. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility on 07/01/22 with diagnoses including edema.
The resident's move-in evaluation failed to address the following required elements:
* Personality including how the person coped with change or challenging situations.
The need to address all required elements of the move-in evaluation was discussed with Staff 1 (ED) and Staff 2 (Regional RN) on 07/21/22. They acknowledged the findings.
C252
OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation
1. Resident #3 evaulation has been updated to reflect personality; including how the person copes with change or challenging situations.
Resident #1 the following inaccuracies on the evaluation have been corrected: independent with all tasks related to dining; undstanding of the facility's fire safety process; assistance needed with wrist brace(s); side rail use; alternative measures and interventions utilized prior to the administration of a psychotropic medication; size of group for activitiy participation; and general skin condition.
Resident #2 the following inaccuracies on the evaluation have been corrected; self administering of an inhaler; understanding the facility's fire safety process; current and past treatments for pain; and general skin condition.
2. To ensure the system will be corrected so this violation will not happen again; evaluations including all required factors will be completed per company policy and Oregon Administrative Rule prior to move-in, updated within 30 days, quarterly thereafter and with any signifcant change of condition. The document should be signed to indicate who completed the evaluation.
3. The area will be reviewed during the weekly high risk Interdisciplinary Team roundtable and audited on a quarterly basis via the routine quarterly evaluation process.
Completion and accuracy of evaluations will be reviewed in daily clinical stand-up prior to ALL new move-in(s) to ensure ALL components are addressed and reflective of resident needs.
4. The Administrator, Licensed Nurse, or designee will be responsible to ensure the system has been corrected and the system is monitored.
2. Resident 1 was admitted to the facility in 04/2018 with diagnoses including mild dementia and anxiety.
The resident's service plan, dated 06/07/22 and Interim Service Plans (ISPs) were reviewed and staff were interviewed. The service plan was not followed, lacked clear direction to staff, or was not reflective of the resident's current needs in the following areas:
* Notifying the RN if the resident received a PRN psychotropic five days in a row;
* The resident's preferred waking time;
* Direction for staff relating to morning routines;
* Side rail use;
* Compression stocking use;
* Wrist brace use;
* Assistance needed with brushing hair and face washing;
* Assistance needed with repositioning in bed;
* Mental health issues;
* Ability to self direct PRN psychotropic medication;
* What caused the resident to exhibit anxiety;
* What interventions staff did to help alleviate the resident's anxiety;
* Medications received via any non-oral routes;
* Medications received for pain management; and
* Dry skin and ability to self direct lotion as needed.
The need to ensure service plans were followed, reflective of the resident's current needs, and provided clear caregiving instruction was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes and encephalopathy.
The resident's 07/10/22 service plan and ISPs were reviewed. Resident 2 was interviewed on 07/20/22 at 1:06 pm and observations were made during the interview. The service plan was not reflective or failed to provide clear caregiving instruction in the following areas:
* Assistance needed for showering;
* Current diet order;
* If the resident wished to self-administer medications;
* What medications the resident self-administered;
* General skin condition;
* Emergency evacuation processes;
* Occasional use of a mobility device; and
* Use of a CPAP machine.
The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
4. Resident 6 was admitted to the facility in 06/2021. The service plan available to staff was dated 07/21/21. There was no documented evidence the resident's service plan had been updated and/or the updates communicated to staff.
The need to ensure service plans were updated at least quarterly and were reflective of the resident's current needs was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
5. Resident 3 was admitted to the facility in 07/2022 with diagnoses including nerve root and plexus disorders.
The resident's 07/15/22 service plan and temporary service plans were reviewed, the resident was interviewed and observations were made. The service plan was not reflective of the resident's needs and preferences and did not give clear instruction to staff in the following areas:
* Transfers including the use of a transfer pole and risks associated with it's use;
* Mobility including the use of a motorized wheelchair; and
* Skin including the use of a palm guard on the left hand daily.
The need to ensure Resident 3's service plan was reflective of their needs and preferences and gave clear instruction to staff was discussed with Staff 1 (ED) and Staff 2 (Regional RN) on 07/21/22. They acknowledged the findings.
6. Resident 4 was admitted to the facility in 08/2020 with diagnoses including exogenous obesity.
The resident's 06/25/22 service plan was reviewed, the resident was interviewed and observations were made. The service plan was not reflective of the resident's needs in the following area:
* CPAP Machine.
The need to ensure Resident 4's service plan was reflective of their needs was discussed with Staff 1 (ED) and Staff 2 (Regional RN) on 07/21/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were followed, were reflective of resident needs, provided clear direction to staff regarding the delivery of services and were updated quarterly for 6 of 7 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:
1. Resident 5's most recent service plan, dated 07/15/22, was not reflective of the following:
* Falls and fall risk;
* Interventions for high dehydration risk;
* Ability to eat independently;
* Wheel chair use;
* Current activity preferences; and
* Current weight loss and weight loss interventions.
On 07/20/22, in an interview with Staff 19 (CG), s/he stated that Resident 5's wheel chair use was recent and that s/he was unaware that resident received hospice care.
In an interview with Witness 1 (Family), they stated the resident was no longer able to transfer independently. They also stated resident's only current activity interest was being outside as his/her health status would allow.
In an interview with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/20/22 they acknowledged the service plan was lacking detail and clear instructions to staff.
The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1, Staff 3 and Staff 4 on 07/21/22.
C260
OAR 411-054-0036 (1-4) Service Plan: General
1. Resident #5 service plan has been updated to reflect fall risk and fall risk interventions; interventions for dehydration risk; ability to eat independently; wheel chair use; current ability preferences; and current weight loss and weight loss interventions.
Resident #1 service plan has been updated to reflect clear direction to staff about the resident's current needs in the following areas: resident's preferred waking time; direction for staff relating to morning routines; side rail use; compression stocking use; assistance needed with brushing hair and face washing; assistance needed with repositioning in bed; mental health issues; ability to self direct PRN psychotropic medication; what causes the resident to exhibit anxiety; what interventions staff use to alleviate the resident's anxiety; medications received via any non-oral routes, medications received for pain management; and dry skin and the resident's ability to self direct lotion as needed.
Resident #2 service plan has been updated to reflect the resident care needs and clear instructions for care staff in the following areas: assistance needed with showering; current diet order; resident wishes related to self-administering medications; what medications the resident can self-administer versus what the community will be assisting with; general skin condition; emergency evacuation processes; occasional use of mobility device; and use of CPAP machine.
Resident #6 service plan has been updated to reflect the resident's current health care status. Staff acknowledgements for understanding the needs of this resident have been communicated to those caring for the resident.
Resident #3 service plan has been updated to reflect the resident's needs and preferences, including clear instruction for staff to follow related to transfer abilities, including the use of a transfer pole and risks associated with it's use; mobility status, including the use of a motorized wheelchair; and skin integrity, including the use of a palm guard on the hand daily.
Resident #4 service plan has been updated to reflect the need of a CPAP machine.
2. This system will be corrected so this violation does not happen again by ensuring that the service plan is updated with any acute or signicant change of condition and with pre-scheduled evaluation updates (initial, 30 days, and quarterly updates) to reflect the resident's current status following all required components outlined in the OARs.
Significant changes of condition are reviewed weekly during the IDT High Risk roundtable meeting. Updates to the service plan will be made during that time if the change has not already been made.
Quarterly, health services and administration will participate with this process to ensure accuracy, personalization, and to involve direct care staff for feedback. The resident and/or the resident's representative will be involved in this process to incorporate resident preferences.
3. The area needing correction will be evaluated at time of move-in, during the 30-day review, quarterly, and as applicable with any change of condition.
4. The Administrator, Licensed Nurse, or designee will be responsible to ensure corrections are completed and montiored.
2. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
Per observation and interview with the resident on 07/20/22 at 1:06 pm, s/he had the following skin issues:
* Front, right lower extremity, red area measuring approximately 5 1/4 inches long and 2 1/2 inches wide;
* Back, right lower extremity, red area measuring approximately 5 1/4 inches long and 2 1/2 inches wide; and
* Front, left lower extremity, red area measuring approximately 5 1/2 inches long and 3 inches wide.
Resident 2 confirmed the facility RN had not looked at the areas and that the resident applied his/her own treatments. It was observed that the resident could not fully reach the area on the back, right lower extremity.
A skin evaluation, dated 07/10/22 stated, "sores on [his/her] legs," and that "these will be closely monitored by [his/her] doctor and the RN." The evaluation was not signed.
There was no documented evidence the facility evaluated the resident's legs or determined if interventions were needed based on the evaluation.
On 07/20/22 at approximately 1:45 pm, Staff 2 (Regional RN) stated she had not looked at the areas on the resident's legs. The surveyor requested Staff 2 to evaluate the resident's legs on 07/20/22 and document what she observed.
On 07/21/22 at 9:45 am, Staff 3 (Director of Operations) stated Staff 2 looked at the resident's skin issues and reported it was scarring. No additional documentation was received.
On 07/21/22, the need to ensure short term changes of conditions were evaluated to determine actions or interventions needed was discussed with Staff 1 (ED), Staff 2, and Staff 3. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 07/2022 with diagnoses including edema and nerve and root plexus disorders (pressure on the spinal nerve root).
The resident's 07/01/22 through 07/20/22 progress notes, 07/15/22 service plan and Interim service plans (ISP's) were reviewed and revealed the following:
* 07/11/22 Outside provider note transcription - "elevate legs more, plus edema in [left] leg."
The facility lacked documented evidence the edema in Resident 3's left leg was evaluated by the facility with interventions determined, documented, communicated to staff on each shift, and the condition monitored with progress noted at least weekly through resolution.
The need to ensure changes of condition were evaluated by the facility with interventions determined, documented and communicated to staff on all shifts and monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Regional RN) on 07/21/22. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored at least weekly to resolution, actions or interventions were determined, documented and communicated to staff, and staff instructions included resident-specific information for 3 of 5 sampled residents (#s 2, 3 and 5) who were reviewed for changes of condition. Resident 5 experienced ongoing falls with injury which posed an immediate threat to the resident's safety and well being. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in March 2022.
a. Review of Resident 5's progress notes dated 04/19/22 through 07/09/22 revealed s/he experienced multiple falls:
* 04/26/22 fall with injury;
* 05/12/22 non-injury fall:
* 05/25/22 non-injury fall;
* 06/15/22 non-injury fall;
* 06/19/22 fall with injury;
* 06/27/22 fall with injury, Resident sent to ER; and
* 07/04/22 fall with injury, Resident sent to ER.
Documented interventions on 05/12/22 instructed staff to "Encourage resident to unlock [his/her] brakes prior to standing up."
An incident report, dated 06/27/22 stated "Have resident use walker to go to the bathroom."
Documentation from the emergency room on 07/4/22 noted the resident had a new diagnosis of acute kidney failure. Resident 5 was admitted to hospice on 07/15/22.
Resident 5's current service plan dated 07/15/22 noted the resident was sent to the hospital for a fall and diagnosed with acute kidney failure. The service plan noted the resident was "unstable with transfer and staff to assist with transfers, showers, go to dining room and activities until [s/he] is back to baseline".
During the survey the resident was observed sitting in a recliner. Witness 1 (Family) assisted the resident to reposition.
Interviews with CGs on 07/20/22 and 07/21/22 revealed the resident no longer went to the dining room and ate meals in his/her apartment. Staff stated the resident was dependent on staff for transfers and escorts.
Resident 5 experienced multiple falls between 04/26/22 through 07/04/22 with head injuries on two occasions. There was no documented evidence each fall was evaluated to determine if interventions were in place or continued to be effective. The interventions noted on the incident report on 06/27/22 were not communicated to staff. In addition, there was no documented evidence the resident's falls were monitored weekly through resolution.
The surveyor requested an immediate plan of correction to minimize or prevent injury falls. The surveyor received a plan of correction on 07/20/22, at which time the situation was abated.
C270
OAR 411-054-0040 (1-2) Change of Condition and Monitoring
1.Resident #5 will have a comprehensive evaluation and service plan updated to address current resident condition and needs. An RN assessment and root cause analysis related to repeat falls with and without injuries will be conducted to identify appropriate interventions to minimize injuries related to the resident's high risk of falls.
Resident #5 will remain on weekly High Risk clinical review will until a new baseline can be established or the resident returns to his/her historical baseline.
Resident #2 will have a comprehensive skin evaluation and service plan update conducted related specifically to resident's skin condition.Current and relevant historical skin conditions will be added to the service plan with appropriate interventions for staff to be made aware of and to follow as applicable.
Resident #3 will have a comprehensive skin evaluation and service plan update conducted related to resident's left leg edema. Clear interventions and instructions will be included for staff to follow as applicable.
Resident #3 will have this condition monitored with progress noted at least weekly through resolution.
2. The community will reimplement the facility policy and procedures related to the 24-hour communication and monitoring system. The system will include any relevant shift to shift communications, a list of residents who are being monitored for alert charting, skin breakdown, and/or RN High Risk (weekly significant change of condition). Staff will follow Short Term Monitoring / Communication System for any resident identified to have an acute change of condition such as, but not limited to UTI, missed medication, return from hospital, falls, swallowing difficulties, etc..
When a change of condition is identified that requires nursing involvement, the resident will be monitored by the staff and a nursing assessment (focused or comprehensive) depending on type of condition change will be completed. All changes of condition will be reflective on the service plan when there are interventions or resident specific instructions needed.
When there is a significant change of condition noted, the resident will be assessed by the RN and will be reassessed by the RN at a minimum of weekly until the condition type resolves and/or a new baseline is established.
Staff will receive in-service training specific to what constitues a short term condition change, a significant change of condition, monitoring requirements, and when the nurse should be notified.
3. The area needing correction will be reviewed daily during stand up and weekly during the high risk IDT roundtable to ensure compliance is maintained.
4. The Administrator and Registered Nurse will be responsible to ensure the corrections are completed and monitored.
2. Resident 1 was admitted to the facility in 04/2018 with diagnoses including anemia, depression, mild dementia and anxiety.
Resident 1 weighed 66 pounds on 04/01/22. The resident's weight was recorded as 71.4 pounds on 05/03/22. This was a 5.4 pound weight increase, which constituted a severe 8.18% gain in one month.
Staff 2 (Regional RN) documented in a progress note dated 07/14/22, "Weight stable for the month. Continue current plan of care."
Per interview on 07/19/22 at 3:38 pm with Staff 2, she stated the resident was formally on hospice services, had been taken off as his/her health improved but did not know when the resident was taken off of hospice services.
An RN assessment was requested on 07/19/22 for the severe weight gain. Staff 2 verified an assessment had not been completed.
The need to ensure an RN assessed residents with a significant change of condition, whether it be a full or problem focused assessment, which included documentation of findings, resident status, and interventions made as a result of this assessment was discussed with Staff 2 on 07/20/22. Staff 1 (ED) and Staff 3 (Director of Operations) were informed of the findings on 07/21/22 which was acknowledged.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 3 of 3 sampled residents who experienced significant changes of condition (#s 1 and 7) related to weight fluctuations. Findings include, but are not limited to:
1. Resident 7 was admitted to the facility in January 2015.
The resident's 06/01/22 through 07/19/22 progress notes, service plan and weight documentation were reviewed.
The following weights were noted:
*03/2022 105.8 pounds;
*04/2022 99.2 pounds;
*05/2022 94 pounds;
*06/2022 95.4 pounds; and
*07/2022 97 pounds.
Between 3/2022 and 4/2022, Resident 7 lost 6.6 pounds or 6.2% of his/her body weight in one month. Between 4/2022 and 5/2022 the resident lost an additional 5.2 pounds or 5.2% of his/her body weight in a month. Resident 7's weights were trending up in 06/2022 and 07/2022.
Observations of the resident between 07/18/22 and 07/21/22 showed the resident was able to feed him/herself once provided food. The resident did not seek out or ask for food items during survey observations but would accept items when staff offered. Resident 7 ate greater than 50% of meals.
In interview on 07/19/22, Staff 3 (RN) verified the assessment lacked resident status and interventions.
Resident 7 experienced a change of condition related to weight loss. There was no documented evidence the facility RN completed an assessment of the weight loss.
The need for an RN assessment related to weight loss was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
C280
OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services
1. Actions taken to correct this rule violation include a comprehensive health assessment by the RN for Resident # 7 to ensure probable causative factors for weight loss are identified and appropriate interventions and monitoring are in place until weight stabilizes.
Resident # 1 will be assessed by the RN to ensure probable casuative factors for weight gain are identified and appropriate interventions and montioring are in place until weight stabilizes.
2. The community will reimplement the facility policy and procedures related to the 24-hour communication and monitoring system. The system will include any relevant shift to shift communications, a list of residents who are being monitored for alert charting, skin breakdown, and/or RN High Risk (weekly significant change of condition). Staff will follow Short Term Monitoring / Communication System for any resident identified to have an acute change of condition such as, but not limited to UTI, missed medication, return from hospital, falls, swallowing difficulties, etc..
When a change of condition is identified that requires nursing involvement, the resident will be monitored by the staff and a nursing assessment (focused or comprehensive) depending on type of condition change will be completed. All changes of condition will be reflective on the service plan when there are interventions or resident specific instructions needed.
When there is a significant change of condition noted, the resident will be assessed by the RN and will be reassessed by the RN at a minimum of weekly until the condition type resolves and/or a new baseline is established.
Staff will receive in-service training specific to what constitues a short term condition change, a significant change of condition, monitoring requirements, and when the nurse should be notified.
3. The area needing correction will be reviewed daily during stand up and weekly during the high risk IDT roundtable to ensure compliance is maintained.
4. The Administrator and Registered Nurse will be responsible to ensure the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:
During the acuity interview on 07/18/22, Resident 2 was identified as receiving insulin injections by non-licensed staff.
Resident 2's 06/01/22 through 07/18/22 MARs were reviewed and showed insulin had been given by Staff 12, 14 and 15 (MTs) on multiple occasions.
Review of delegation documentation revealed the following:
a. The nursing assessment and condition of the resident lacked documented evidence of how the resident's condition was stable and predictable and a rationale that the task could be safely delegated to non-licensed staff.
b. Initial delegations for Staff 12, completed 05/16/22, Staff 14, completed 05/23/22, and Staff 15, completed 05/12/22, lacked documentation in one or more of the following areas:
* The skills and ability of the unlicensed person;
* Written instructions which included risks, side effects, response and risk factors;
* The taught task was resident specific;
* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the resident's needs; and
* The rationale for the frequency the unlicensed person should be supervised and re-evaluated based on the competency of the MTs.
There was no documentation that Staff 2 (RN) re-evaluated Staff 14 within 60 days of the initial delegation. Although there was documentation Staff 15 was re-evaluated on 07/13/22, there was no documented evidence of her initials on the MAR verifying she was the one who administered Resident 2's sliding scale or routine insulin on that day.
The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 2 and Staff 3 (Director of Operations) on 07/21/22. They acknowledged the findings.
C282
OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching
1. Resident #2 will have a comprehensive nursing assessment with documented evidence of that the resident is stable and predictable to engage with RN Delegation. Additionally, the rationale that the task can be safely delegated to non-licensed staff will be clearly documented.
Staff #12, #14 and #15 will have a comprehensive nursing review of delegations and be re-delegated in accordance with OSBN Division 47 Rules.
2. The RN will complete the RN Delegation in Community Based Care self study guide and attend the OHCA Role of the Community Based Care Nurse.
The RN will be trained on the components that should be included in an assessment specific to delegations.
All non-licensed staff performing delegated task will have signed evidence that the delegation process occurred, including the competency of the non-licensed staff and rationale for the frequency that the the non-licensed staff will be re-evaluated.
All Delegations will be maintained in accordance with the Oregon State Board of Nursing Division 47 Rules.
3. The area needing correction will be evaluated on a monthly basis.
4. The Registered Nurse will responsible for ensuring corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to implement recommendations from the outside provider in order to ensure the continuity of care for 1 of 1 sampled resident, (# 3) who received services from an outside provider. Findings include, but are not limited to:
Resident 3 was admitted to the facility in 07/2022 with diagnoses including edema.
Resident 3's clinical records identified the resident received HH services for pain management and edema.
A review of resident's clinical record indicated communication from the outside provider had been transcribed into the residents record. HH left documentation identifying edema in the left leg and instructions to elevate Residents 3's legs. There was no evidence the facility followed the instructions or evaluated the edema.
On 07/20/22 at 10:44 am, Staff 2 (Regional RN) confirmed she was unaware the resident had edema and staff had not received instructions to elevate Resident 3's legs.
The facility lacked an effective system to ensure implementation of any clinical information or recommendations left by the outside provider necessary for facility staff to provide supplemental care.
On 07/21/22, the need to ensure on-going coordination of care for residents receiving on and off-site health services was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.
C290
OAR 411-054-0045 (2) Res Hlth Srvc: On-and Off-Site Health Srvc
1.Resident #3 service plan will reflect services being provided by Home Health, including staff interventions applicable related to left leg edema.
2. All documentation received by on or off site services will be processed through the triple check, multi-staff verification system. All documents should be processed simliar to the receipt of a new order to ensure staff are informed of current or new interventions.
The service plan will be updated to reflect any changes made to the current plan of care and/or any new or discontinued interventions or recommendations being made by the ancillary service provider.
The community will utilize an 'outiside provider form' to capture clear notes by the provider. All outside providers will be educated to sign in and utilize the form during each visit.
3. The system will be reviewed weekly during the high risk IDT roundtable and monthly during the QA meeting.
4. The Administrator, Licensed Nurse, or designee will be responsible to see that the corrections are completed and monitored.
Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication and treatment administration system and failed to ensure adequate professional oversight of the systems. The facility failed to administer a monthly dose of medication to Resident 3. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including hypothyroidism, hyperlipidemia and hypertension.
Resident 3 had a physician's order for Repatha (to treat hyperlipidemia) 3.5 ml subcutaneously once a month, during the day shift, on the fourth. The facility lacked documented evidence the medication was administered to the resident on 07/04/22.
Refer to C303, example 1 a.
2. During the re-licensure survey, conducted 07/18/22 through 07/21/22, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following areas:
* C 282: RN Delegation and Teaching;
* C 303: Medication and Treatment Orders;
* C 310: Medication Administration;
* C 325: Self Administration of Medications; and
* C 330: PRN Psychotropic Medications.
During the exit interview on 07/21/22, Staff 1 (ED) and Staff 2 (Regional RN) were informed the medication and treatment administration system was determined to be inadequate based on the number of deficiencies related to the above medication areas. They acknowledged the findings.
C300
OAR 411-054-0055 Systems: Medications and Treatments
Please refer to the following deficiencies for POC under C300 to ensure a safe medication system and adequate professional oversight:
*C282: RN Delegation and Teaching
*C303: Medication and Treatment Orders
*C310: Medication Administration
*C330: PRN Psychotropic Medications
2. Resident 1 was admitted to the facility in 04/2018 with diagnoses including depression, mild dementia and anxiety.
The resident's 07/01/22 through 07/18/22 MAR and physician's orders were reviewed. The facility did not have a physician's order for mirtazapine (to treat depression and stimulate appetite) in the resident's facility record but the medication was listed on the MAR.
The need to have physician orders in the resident's facility record was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
3. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
The resident's 06/01/22 through 07/18/22 MARs and physician's orders were reviewed.
a. The following physician orders were not in the resident's facility record:
* Admelog Solostar insulin (to treat diabetes), sliding scale, to be administered three times a day depending on the resident's CBGs;
* Admelog Solostar insulin, 46 units to be administered three times a day;
* Furosemide (to treat fluid retention) 40 mgs to be administered at 3:00 pm every day;
* Lactulose (to treat hepatic encephalopathy) to be administered TID;
* Nortriptyline (to treat neuropathic pain);
* Ozempic (to treat diabetes) to be administered every seven days;
* Spironolactone (to treat fluid retention);
* PRN albuteral (to treat shortness of breath);
* PRN benzonatate (to treat cough);
* PRN diclofenac sodium gel (to treat pain);
* PRN Eucerin cream (to treat dry skin); and
* PRN guaifenesin (to treat chest congestion and cough).
b. Xifaxan (to treat hepatic encephalopathy) was not administered on 17 occasions due to the "Medication not available/Pharmacy contacted."
c. The following physician's orders were not reflected on the MAR:
* Vitamin D (supplement);
* Insulin lispro (to treat diabetes); and
* Melatonin (to treat insomnia).
d. On 05/24/22, Staff 11 (MT/CG) documented in a progress note that the resident requested "compression socks."
Resident 2's admitting physician's orders stated, "ordered daily compression to legs with provided ace bandages to [previous] ALF." This was ordered relating to bilateral lower extremity edema, "well healing lesions" and "skin changes" from "chronic venous stasis."
On 07/20/22 at 1:06 pm, the resident confirmed s/he did not have compression socks and did want them.
The need to have physician orders in the resident's facility record and to ensure staff were following physician's orders was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for all medications and treatments the facility was responsible to administer for 3 of 4 sampled residents (#s 1, 2 and 3) whose orders were reviewed. The facility failed to administer a monthly dose of medication to Resident 3 placing the resident at risk for serious harm. Findings include, but are not limited to:
1. Resident 3 was admitted to the facility in 07/2022 with diagnoses including hypothyroidism, hyperlipidemia and hypertension.
The resident's 07/01/22 physician's orders and 07/01/22 through 07/18/22 MARs and TARs were reviewed and revealed the following:
a. Resident 3 had a physician's order for Repatha (to treat hyperlipidemia) 3.5 ml subcutaneously once a month, during the day shift, on the fourth. The facility lacked documented evidence the medication was administered to the resident on 07/04/22.
During an interview on 07/19/22 at 10:33 am, Staff 2 (Regional RN) revealed she was unaware Resident 3 was prescribed the medication. At 4:18 pm, Staff 2 was able to locate the medication in the medication room's refrigerator.
During an interview on 07/20/22 at 11:13 am, the resident confirmed s/he did not receive the medication on 07/04/22.
Failure to follow to the prescribed dosage of Repatha can decrease the efficacy of the medication in the body, and put the resident at risk for high cholesterol which could lead to coronary heart disease, stroke and peripheral vascular disease. By failing to follow the order as prescribed, the facility put the resident at risk for harm.
The facility was asked to develop an immediate plan of correction on 07/19/22 to keep Resident 3 safe from the risks of the missed dose of Repatha. The situation was abated on 07/19/22.
b. The facility lacked physician's orders for the following administered medications:
* Fluticasone 500 mg nasal spray (to treat allergies); and
* Levothyroxine 100 mg (to treat hypothyroidism).
c. The facility failed to follow physician's orders for the following medications and treatments which were not present on MARs and TARs:
* Acetaminophen 325 mg PRN (to treat pain);
* Dulcolax suppository 10 mg PRN (to treat constipation);
* Fleet Enema PRN (to treat constipation);
* Ferrous sulfate PRN (to treat anemia);
* Compression stockings (to treat edema); and
* Left hand palm care including daily cleaning and palm guard (skin guard).
d. The following physician's orders were not followed as prescribed:
* Losartan 25 mg (to treat hypertension) was to be administered in the evening, but the MAR showed the administration time as 8:00 am.
During an interview on 07/20/22 at 11:16 am, Staff 2 stated she was unaware the Losartan was prescribed during the evening.
The need to ensure physician's orders were carried out as prescribed and written signed physician or other legally recognized practitioners orders were documented in the resident's record for all medication and treatments the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 2 on 07/21/22. They acknowledged the findings.
C303
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
1. Resident #3, Resident #1, and Resident #2 will have a physician order reconciliation completed to ensure all orders are carried out per written orders and to verify that all medications or treatments ordered are available to be provided or administered as written.
2. A comprehensive medication/treatment reconciliation will be completed for all residents. A three-way chart, to cart, to EMAR audit will be completed to ensure only current orders are being provided.All new orders will be reviewed and approved by a minimun of two staff. Daily reports will be ran and audited to identify any missing medications, medication or treatment omissions, and residents that have utilized one or more PRNs in the last 24 hours.
3. The system will be monitored on a daily basis.
4. The Nurse, Administrator, or trained designee will be responsible to ensure the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 1 of 5 sampled residents (# 8) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 8 was admitted to the facility in 2018 with diagnoses including Type II diabetes and chronic pain.
A record review of resident's 01/01/23 through 01/17/23 MAR, showed 1300 mg of Acetaminophen was administered to the resident, not 650 mg as prescribed.
a. Resident 8 had a physician's order, dated 07/30/21, to administer Glucose 40 % gel or four ounces of juice if able to take by mouth when blood sugar was level less than 70.
The resident's 12/01/22 through 12/16/22 and 01/01/23 through 01/17/23 MAR showed the blood sugar level was 61 on 12/03/22 and 69 on 12/12/22 and 01/01/23. There was no documented evidence of administrating Glucose 40 % gel or four ounces of juice as prescribed.
b. Resident 8 had a physician's order, dated 11/21/22, to administer Trazadone 75 mg at bedtime as needed for sleep.
The resident's 01/01/23 through 01/17/23 MAR showed the medication was administered daily at bedtime as scheduled, not as needed as prescribed.
Resident 8's current signed physician order and 01/01/23 through 01/17/23 MAR/TARs were reviewed.
c. The following was ordered by the physician:
* Alum-mag hydroxide-simeth (to treat heartburn and stomach upset) 200-200-20 mg suspension 30 ml by mouth.
There was no clear instruction how frequently to administer those medications to the resident.
d. The following was ordered by the physician:
* Acetaminophen 325 mg one to two tablet by mouth every six hours as needed for pain;
* Narcan (to treat a known opioid overdose emergency); and
* Epson salt to soaks of both feet twice weekly for 15-30 minutes to promote skin integrity of feet.
There was no indication these orders were transcribed to the MAR or TAR to carry out.
The need to ensure physician's orders were carried out as prescribed was discussed with Staff 3 (VP of Operations) and Staff 21 (Operations Specialist) on 01/18/23. They acknowledged the findings.
Citation 303
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
Physician's Orders will be sent to all primary care physicians once monthly for the next 60 days, then every 90 days after, to ensure that all medications and treatments are being administered correctly. Once established all medication orders will be processed using a 3-check system. Which includes but is not limited to checks being done by the Med techs, Resident Care Coordinator and the Health Services Director. This will be done upon receipt of physician order.
Effective immediately
Responsible parties will include
Resident Care Coordinator
Health Service Director
Executive Director
Alleged Compliance date no later than March 4, 2023
Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications the facility was responsible to administer and/or failed to ensure physician orders were carried out as prescribed for 3 of 3 sampled residents (#s 2, 13 and 14) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
Resident 2's 04/01/23 through 04/18/23 MARs and physician's orders were reviewed.
There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments that the facility was responsible to administer:
*Basaglar Kwikpen 100 units every day (insulin);
*Gabapentin 300 mg twice daily (nerve pain);
*Lidocaine 5% ointment up to three times daily (pain);
*Nystatin twice daily (yeast infection);
*Steglatro 5 mg every day (diabetes);
*Trazadone 100 mg daily (insomnia); and
*Xifaxan 550 mg (cirrhosis of liver).
The need to ensure signed physician orders were in the resident's record for all medications administered was discussed with Staff 25 (Administrative Designee) and Staff 26 (RN) on 04/18/23. Staff 26 began faxing the resident's physician to obtain current signed orders.
2. Resident 13 was admitted to the facility in 2018 with diagnoses including hypertension and diabetes.
On 12/13/22 the physician directed staff to check the resident's blood sugar twice daily in the morning and evening.
Resident 13's 04/01/23 through 04/18/23 MARs noted the resident's blood sugar was being tested once daily instead of twice as ordered.
During an interview with Staff 26 on 04/18/23 at 1:30 pm, she stated the resident's physician had been faxed for clarification.
3. Resident 14 was admitted to the facility in 2019 with diagnoses including coronary artery disease and hyperlipidemia.
Resident 14's 04/01/23 through 04/18/23 MARs and after visit summary notes were reviewed.
There was no documented evidence the facility had written, signed physician or other legally recognized practitioner orders documented in the resident's facility record for the following medications and treatments the facility was responsible to administer:
*Amlodipine 2.5 mg every day (hypertension);
*Garlic oil 500 mg every day (supplement);
*Ibuprofen 200 mg every day (pain);
*Levothyroxine 75 mcg every day (hyperthyroidism);
*Simvastatin 20 mg every day (hyperlipidemia);
*Vitamin B complex liquid every day (supplement);
*Vitamin C 125 mg every day (supplement);
*Vitamin D3 every day (vitamin d deficiency);
*Tylenol 500 mg PRN every four hours (pain);
*Mylanta PRN (upset stomach);
*Milk of magnesium PRN (constipation); and
*Secura protective cream PRN (skin integrity).
The need to ensure signed physician orders were in the facility records for all medications administered was discussed with Staff 25 (Administrative Designee) and Staff 26 (RN) on 04/18/23. Staff 26 began faxing the resident's physician to obtain current signed orders.
Citation 303
OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders
The process from the previous POC has already been underway. Updated Physician's Orders will be requested again from residents' PCPs who have not responded and persist until orders are in hand. Repeat the process in 30 days, then every 90 days after, to ensure that all medications and treatments are being administered correctly. Once established all medication orders will be processed using a 3-check system, which includes but is not limited to checks being done by the Med techs, Resident Care Coordinator and the Health Services Director. This will be done upon receipt of physician order.
Responsible parties will include
Resident Care Coordinator/Staff Coordinator
Health Service Director
Executive Director
Alleged Compliance date no later than May 17, 2023
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate, included reasons for use, and provided clear instruction and parameters for administration of PRN medications for 3 of 4 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 04/2018 with diagnoses including mild dementia.
The resident's 07/01/22 through 07/18/22 MAR was reviewed. The resident had two PRN medications prescribed for constipation. There was no documented evidence of direction to staff relating to when the medications should be administered or the order in which the medications should be administered.
The need to ensure MARs were accurate and provided resident specific directions or parameters was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
2. Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
The resident's 06/01/22 through 07/18/22 MARs were reviewed and the following inaccuracies were identified:
a. The following medications lacked a reason for use:
* Admelog Solostar, sliding scale;
* Admelog Solostar, scheduled;
* Furosemide;
* Spironolactone;
* Xifaxan; and
* Diclofenac sodium gel.
b. The following PRN medications lacked clear directions and/or resident specific parameters for unlicensed staff to follow:
* Albuteral (to treat shortness of breath);
* Diclofenac sodium gel (to treat pain); and
* Ondeansetron (to treat nausea).
The need to ensure MARs were accurate, listed reasons for use and provided resident specific directions or parameters was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. They acknowledged the findings.
3. Resident 3 was admitted to the facility in 07/2022 with diagnoses including edema, hyperthyroidism, hypertension and hyperlipidemia.
Resident 3's 07/01/22 through 07/19/22 MARs and TARs were reviewed and the following deficiencies were identified:
a. The following medications lacked reasons for use:
* Bupropion XL 150 mg;
* Citalopram 40 mg;
* Clobetasol 0.05% ointment;
* Eliqus 5 mg;
* Fluticasone 50 mg mcg;
* Furosemide 80 mg;
* Gabapentin 300 mg;
* Levothyroxine100 mcg;
* Losartan 25 mg;
* Oxybutynin ER 10 mg;
* Potassium ER 20 mg;
* Repatha syringe 420 mg; and
* Roponirole 0.25 mg.
b. The facility failed to follow physician's orders for the following medications and treatments which were not present on MARs and TARs:
* Acetaminophen 325 mg PRN (to treat pain);
* Dulcolax suppository 10 mg PRN (to treat constipation);
* Fleet Enema PRN (to treat constipation);
* Ferrous sulfate PRN (to treat anemia);
* Compression stockings (to treat edema); and
* Left hand palm care including daily cleaning and palm guard (skin guard).
The requirement for MARs to be accurate and include reasons for use for each medication and treatment was discussed with Staff 1 (ED) and Staff 2 (Regional RN) on 07/21/22. They acknowledged the findings.
C310
OAR 411-054-0055 (2) Systems: Medication Administration
1. Resident #1, Resident #2, and Resident #3 will be corrected to ensure the MAR reflects clear instructions for all medications and a reason for use. All residents with PRNs will have clear instructions on the order of sequence for administraiton medications prescribed for the same use.
2. A comprehensive medication/treatment reconciliation will be completed for all residents. A three-way chart, to cart, to EMAR audit will be completed to ensure only current orders are being provided.All new orders will be reviewed and approved by a minimun of two staff. Daily reports will be ran and audited to identify any missing medications, medication or treatment omissions, and residents that have utilized one or more PRNs in the last 24 hours.
3. The system will be monitored on a daily basis.
4. The Nurse, Administrator, or trained designee will be responsible to ensure the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications, for 1 of 2 sampled residents (#2) who self-administered their medications. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 03/2022 with diagnoses including diabetes.
An evaluation, dated 07/10/22, indicated Resident 2 self-administered his/her diclofenac gel (to treat pain). This was confirmed by facility staff.
An interview on 07/20/22 at 1:06 pm, the resident confirmed s/he self-administered the diclofenac gel.
Resident 2 lacked documented evidence of an order from a physician indicating approval for the resident to self-administer his/her prescription medications.
The lack of signed orders indicating a physician's approval for Residents 2 to self-administer their medications was reviewed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. No additional information was received.
C325
OAR 411-054-0055 (5) Systems: Self-Administration of Meds
1. Resident #2 orders will be clarifed to ensure the resident is capable and aware on how to administer non-oral medications or treatments.
2. A comprehensive record review of all residents will be conducted to identify which residents are self administering medications or treatments. All residents who are self administering medications or treatments will have an evaluation conducted to determine abilities to safely self manage.
3.This system will be audited monthly and quarterly during the evaluation and service planning process.
4. The Licensed Nurse, Administrator, or trained 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 PRN psychotropic medications used to treat a resident's anxiety had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed a PRN medication to address anxiety. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 04/2018 with diagnoses including mild dementia and anxiety.
Review of the resident's 07/01/22 through 07/18/22 MAR and current physician orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication), one tablet every four hours as needed for anxiety.
The facility administered the Lorazepam to the resident on 32 occasions during the above mentioned look back period.
The MARs lacked resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication.
The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented as not effective prior to administration of the medication was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 4 (RCC) on 07/21/22. The staff acknowledged the findings.
C330
OAR 411-054-0055 (6) Systems: Psychotropic Medication
1. Resident #1 MAR will be audited and corrected to ensure resident specific parameters for use of PRN psychoactive medications are in place. Additionally, staff will have instructions in place to utilize resident specific non-pharmaceutical interventions prior to administration.
2. Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse. A documented antipsychotic medication evaluation will be completed and the primary care physician or provider will be notified. The Licensed Nurse will ensure appropriate resident indicators for use are in place as well as non-pharmaceutical interventions staff should offer prior to using. All active PRN psychoactive medications will be reviewed prior to quaterly physician order sent for signature as well as with scheduled PRN medication audits.
3. This area wil be elevated on a quarterly basis prior to sending quarterly physician orders for MD review and signature, on a monthly basis wth medication administration audits and daily with triple check review if a new order is received.
4. The Licensed Nurse and Administratore will be responsible to see that the corrections are completed and montiored.
Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and dementia care training had been completed, with certification, prior to staff providing direct care to residents for 4 of 4 newly hired caregiving staff (#s 9, 10, 18 and 20). Findings include, but are not limited to:
Staff training records were reviewed on 07/21/22.
1. Staff 9 (CG) was hired on 07/04/22 and Staff 10 (MT) was hired on 05/23/22.
a. Staff 9 and 10's training records lacked documented evidence of completing orientation training, prior to beginning job responsibilities, in the following area:
* Infectious Disease Prevention.
b. Staff 9 and 10 training records lacked documented evidence of pre-service dementia training with certification in the following areas:
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communication and responses to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.
2. Staff 18 (CG) was hired on 06/23/22 and Staff 20 (MT) was hired on 06/27/22.
a. Staff 18 and 20 training records lacked documented evidence of completing orientation training, prior to beginning job responsibilities, in the following area:
* Infectious Disease Prevention;
* Fire safety and emergency procedures; and
* A written job description.
b. Staff 18 and 20 training records lacked documented evidence of pre-service dementia training with certification in the following areas:
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communication and responses to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, and the use of person-centered approach.
The training program and requirements were discussed with Staff 1 (Executive Director) and Staff 4 (RCC) on 07/21/22. No additional information was provided.
Staff 9, 10, 18 and 20's training records were discussed with Staff 1 (Executive Director) and Staff 3 (Director of Operations) on 07/21/22. Staff acknowledged the findings.
C370
OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts
1. Immediate actions to correct the rule violations include ensuring staff #9, #10 , #18 and #20 have documented evidence of completing orientation training in the following area:
* Infectious Disease Prevention
and have documented evidence of pre-service dementia training with certification in the following areas:
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms.
* Techniques for understanding communication and responses to distressful behavioral symptoms.
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities.
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food / fluids, preventing wandering, and the use of person-centered approach.
Staff #18 and #20 will have documented evidence of completing orientation training in the following areas as well:
* Fire safety and emergency procedures.
* A written job description.
2. The system will be corrected so this violation does not happen again by :
* Completing a comprehensive training record audit of all trainings and competencies completed and documented on a training log for review.
* Any missing competencies and training will be completed for currently employed staff.
* Staff will utilize a combination of Oregon Care Partners, Relias, med tech training meetings, and monthly staff meetings to meet the annual in-servicing requirements.
* Staff will submit certificate 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 record review.
4. Business Office Manager, 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 direct care staff (#s 9, 10, 18 and 20) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:
Staff training records were reviewed on 07/21/22.
1. Staff 9 (CG) hired 07/24/22, Staff 18 (CG) hired 06/23/22 and Staff 20 (MT) hired 06/27/22 failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.
2. Staff 10 (MT) hired 05/23/22 failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:
* Changes associated with normal aging; and
* Identification, documentation and reporting of changes of condition.
The requirement to demonstrate competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Executive Director) and Staff 3 (Director of Operations) on 07/21/22 at 11:30 am. No additional information was provided.
C372
OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff
1. Immediate action taken to correct this rule violation to include ensuring staff #9 (CG), #18 (CG) and #20 (MT) will have documented evidenced of competency demonstrated in all assigned job duties in the following areas:
* Role of service plans in providing individualized care.
* Providing assistance with ADL's.
* Changes associated with normal aging.
* Identification, documentation and reporting of changes of condition.
* Conditions that require assessment, treatment, observation and reporting.
* General food safety, serving and sanitation.
Staff #10 (MT) will have documented evidenced of competency demonstrated in all assigned jobs duties in the following areas:
* Changes associated with normal aging.
* Identification, documentation and reporting of changes of condition.
2. The system will be corrected so this violation does not happen again by:
* Completing a comprehensive training record audit of all trainings and competencies completed and documented on a training log for review.
* Any missing competencies and training will be completed for currently employed staff.
* Staff will utilize a combination of Oregon Care Partners, Relias, med tech training meetings, and monthly staff meetings to meet the annual in-servicing requirements.
* Staff will submit certificate 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. Business Office Manager, 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 2 of 2 long-term staff (#s 15 and 17) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:
1. Staff 15 (CG/MT) was hired 11/2016. Annual training records were reviewed for the year 11/2020 through 11/2021. There was no documented evidence Staff 15 completed 12 hours of annual in-service training.
2. Staff 17 (MT) was hired 06/2018. Annual training records were reviewed for the year 06/2020 through 06/2021. There was no documented evidence Staff 17 completed 12 hours of annual in-service training.
The need to ensure 12 hours of annual in-service training was completed for long term staff was reviewed with Staff 1 (Executive Director) and Staff 3 (Director of Operations) on 07/21/22. No additional information was provided.
C374
OAR 411-054-0070 (5-7) Annual Training and Other Requirements
1. Action taken to correct this rule violation includes:
Staff #15 and #17 will complete the minimum required 12 hours of annual in-service training.
2. The system will be corrected so this violation does not happen again by:
* Completing a comprehensive training record audit of all trainings and competencies completed and documented on a training log for review.
* Any missing competencies and training will be completed for currently employed staff.
* Staff will utilize a combination of Oregon Care Partners, Relias, med tech training meetings, and monthly staff meetings to meet the annual in-servicing requirements.
* Staff will submit certificate 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. Business Office Manager, 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 all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:
Review of fire drill and fire and life safety records from February 2022 through July 2022 identified the following:
* The facility failed to provide fire and life safety instruction to staff on alternate months;
* Escape route used; and
* Problems encountered, comments relating to residents who resisted or failed to participate in the drill were not documented.
The need to ensure the facility documented all required elements for fire drills and provide fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 5 (Environmental Services Director) on 07/19/22. They acknowledged the findings.
C420
OAR 411-054-0090 (1-2) Fire and Life Safety: Safety
1. Actions taken to correct the rule violation will include:
a. Facility will conduct unannouced fire drills every other month at different times of the day, evening, and night.
b. Fire and life safety instruction to staff will be provided on alternate months.
c. Written fire drills will be kept that include but not limited to:
* Location of simulated fire origin;
* The escape route used;
* Problems encountered and comments related to residents who resisted or failed to participate in the drills;
* Evacuation time period needed; and
* Number of occupants evacuated.
2. The system will be corrected so this violation does not happen again by completing a comprehensive reivew of current fire drill forms to ensure they meet the requirements of the Oregon Adminsitrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required,
3. The area needing correction will be evaluated monthly.
4. The Administrator or designee will be responsible to ensure corrections are completed and montiored.
Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:
Fire drill records from 02/2022 through 07/2022 were reviewed.
The facility lacked documentation that residents were re-instructed, at least annually, in 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.
The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 (ED), Staff 3 (Regional Director of Operations) and Staff 5 (Environmental Services Director) on 07/19/22. They acknowledged the findings.
C422
OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents
1. Immediate action taken to correct this rule violation includes all residents will be instructed on general safety proceduresm 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 reinstructed annually.
2. The system will be corrected so this violation will not happen again by ensuring new residents will be instructed within 24 hours of move-in and re-instructed annually for 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.
3. The area needing correction will be audited daily at stand-up meeting and clincal meeting with a new resident move-in.
4. The 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 their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 303.
Citation 455
OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval
Community will continue compliance as stated with corrections to Citations 303 and 640.
Responsible parties are to include
Executive Director
Health Services Director
Resident Care Coordinator
Environmental Director
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 C303.
Refer to C303.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure covers, grates, or surfaces of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:
During an environmental tour on 01/18/23 at 9:20 am, a wall-mounted heater was observed in the bedroom of a resident apartment located where a resident could come into incidental contact with the heater. When the heater was turned on, the surface temperature of the grate measured with the surveyor's thermometer was 196.1 degrees F.
During an observation and interview with Staff 5 (Environmental Services Director) on 01/18/23 at 9:46 am, an empty one bedroom apartment was toured. When the wall mounted heater was turned on, the surface temperature of the grate measured with the surveyor's thermometer was 177.0 degrees F.
In an interview on 01/18/23 at 11:00 am, Staff 5 stated there were 18 one bedroom units that had wall-mounted heaters in the bedroom areas located where residents could come in incidental contact with them.
The need to ensure residents could not come into incidental contact with wall heater grates that exceeded 120 degrees F was discussed with Staff 21 (Operations Specialist), Staff 3 (VP of Operations) and Staff 5. Staff acknowledged the findings. Staff 3 provided an immediate plan of correction which included disconnecting power to the wall mounted heaters by the end of the day on 01/18/23.
Citation 640
OAR 411-054-0300 (8) Heating and Ventilation
All cadet heaters in the resident apartments have been disconnected and will remain so until stay cool cage type covers are available and/or received to place over the cadet heaters. Any apartments where the cadet heater is found does have additional heating sources. Cadet heaters will be checked every 90 days to ensure that cadet heaters are still disconnected. If covers are in place Environmental Service Director will check to ensure that covers are securely placed and placed properly.
This will be effective immediately and once covers are placed.
Responsible parties are to include
Environmental Service Director
Executive Director
Alleged Compliance date no later than March 4, 2023.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the ALF. Findings include, but are not limited to:
The first floor of the Assisted Living area of the building included the main entrance, two additional doors by which residents could exit the building into the outdoor neighborhood, and two doors which exited to an exterior courtyard.
The facility was toured on 07/18/22. There was no system in place for the courtyard and main doors which alerted staff when a resident exited the ALF building.
The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (ED), Staff 3 (Director of Operations) and Staff 5 (Environmental Services Director) on 07/19/22. Staff 5 installed exit door alarms to the patio courtyard doors on 07/19/22.
C655
OAR 411-054-0300 (11-13) Call System
1. Actions taken to correct this rule violation include:
Installation of alarm system to exit doors located at the main entrance, two additional doors by which residents could exit the building into the outdoor neighborhood, and two doors which exited to an exterior courtyard.
2. The system will be corrected so this violation does not happen again by monthly facilities audits of exit door alarm systems to ensure proper functioning. Staff will receive in servicing on reporting urgent and non-urgent repairs via facility maintenance log or Administrator if urgent.
3. The area needing correction will be evaluated weekly and monthly via maintenance log review and community walk through.
4. The Administrator and Maintenance Director will be responible ensuring corrections are completed and monitored.