The findings of the re-licensure survey, conducted 8/30/21 through 8/31/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the relicensure survey of 08/31/21, conducted 03/30/22 through 03/31/22, 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.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey on 08/31/21, conducted  06/14/22 through 06/15/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to ensure the new move in evaluation contained all required elements for 1 of 1 sampled resident (#3) reviewed as a new move in.  Findings include, but are not limited to:

Review of Resident 3's new move in evaluation, dated 6/23/21, lacked the following elements:

* Customary routines: eating and bathing;

* Spiritual cultural preferences and traditions;

* List of current diagnosis;

* List of medications and PRN use;

* Visits to health practitioner, ER or hospital stays in the past year;

* History of mental health treatment;

* Effective non-drug interventions for mental health;

* Memory, orientation, confusion and decision making abilities;

* Personality and how the person copes with change and challenging situations;

* Pharmaceutical interventions for back pain;

* Nutrition habits, fluid preferences and weight;

* List of treatment types frequency and level of assistance needed;

* Environmental factors that impact the resident's behavior including noise, lighting    and room temperature.

* Fall risk and history; and

* History of dehydration and or unexplained weight loss or gain.

The need to ensure all required components were included in the new move in evaluation was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Pre-move evaulation was updated, reviewed and the fire safety evacuation was incorporated into the evaluation form.

All new changes from the evaluation were put onto the care plans and staff was inserviced on all changes.  

Each Section of the pre-move in evaluation will be acknowledged and completed by Admininstrator, LPN or RN before resident is admitted to the facility.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required components for 2 of 3 sampled residents (#s 5 and 6) whose new move-in or quarterly evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted in 02/2022.

The new move in evaluation failed to address the following areas:

* Customary routine: Eating and bathing;

* Mental Health issues: History of treatment;

* Personality, including how a person copes with change or challenging situations;

* Housework and laundry;

* Pain: How a person expresses pain and discomfort;

* Nutrition habits, fluid preferences, and weight if indicated;

* Complex medication regimen;

* Recent losses; and

* Environmental factors that impact the resident's behavior including noise, lighting and room temp.

The need to ensure move-in evaluations included all required components was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 2019 with diagnoses which included Alzheimer's dementia, anxiety and hypertension.

Observations, staff interviews and review of the record during the survey revealed s/he required full assistance with most ADLs and was currently receiving hospice services.

The most recent evaluation, dated 02/28/22, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Personality: including how the person copes with change or challenging situations;

* Ability to use a call system;

* Indicators of nursing needs including potential for delegated nursing tasks; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

On 03/31/22, the need to ensure Resident 6's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator). She acknowledged the findings. No other information was shared.

The pre-move evaluation was updated and a new form including the fire and life safety was added to the packet.  The form requires a signature demonstrating knowledge of instructions.  The form will also be used for yearly reviews with all residents.  A notation will be made for those residents with limited cognition and abilities.

A map of the facility was placed in all resident rooms indicating individual and personalized fire routes, staging areas, and exits that each resident would follow in an emergency situation.   

All information will be addressed on the care plans and temporary care plans will be created to alert staff of any new and changing cares.

Each section of the pre-move in evaluation will be acknowledged and completed by LPN, Administrator or RN before resident is admitted to the facility.

Staff was inserviced on all new forms

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

1. Resident 1 was admitted to the facility in 8/2018.

Staff identified Resident 1 to be dependent for all ADL care and required two staff for transfers. Resident 1 had a wound to the left heel being treated by a Home Health agency.  Staff also reported Resident 1 was in a relationship with another resident.

Resident 1 was observed to utilize a wheelchair for mobility and had bi-lateral side rails on his/her bed.

Resident 1's service plan did not provide clear direction to staff for:

* Transfer assistance including the use of a lift;

* Side rail use including risks and precautions;

* Instructions for wound care during bathing; and

* Relationship with another resident.

2. Review of resident 2's most current service plan dated 1/22/21 revealed his/her service plan was not updated at least quarterly.

3. Review of Resident 3's initial service plan dated 6/29/21 revealed his/her service plan was not updated within 30 days of move in.

The need to ensure service plans were reflective of care needs, provided clear direction to staff, and were updated within 30 days and quarterly was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Care plans have been updated, reviewed and all new information including but not limited to was included:

lift use, wound care, relationships, side rails, wheelchair use etc.

The LPN, RN and Administrator will be monitoring care plans and Quarterly reviews to assure dates remain within the 30 to 90 day window.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 wad admitted in 03/2022.

During the entrance conference acuity interview on 01/03/22, staff indicated Resident 5 needed assistance with ADLs, two staff were often needed for transfers, and was receiving hospice services.

Observations, interviews with the resident and staff, and review of the clinical record revealed the service plan was not reflective or failed to provide clear direction to staff in the following areas:

* Oxygen use;

* Velcro boot on left foot;

* Laundry and housekeeping services;

* Staff assistance to make bed;

* Use of a walker and wheelchair; and

* Glasses for visual impairment.

The need to ensure the service plan was reflective of Resident 5's current needs and provided clear direction to staff was reviewed with Staff 1 (Administrator) on 03/31/22 at 3:00 pm. She acknowledged the findings.

2. Resident 6 was admitted in 2019.

Review of the clinical record, interviews with care staff and observations of Resident 6 were made during the survey. His/her service plan, dated 02/28/22, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Hospice services;

* Bathing; and

* Ability to use a call light.

The need to ensure the service plan was reflective of Resident 6's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) on 03/31/22. She acknowledged the findings. No further information was provided.

Care plans have been updated and reviewed. All care plans have been incorporated with all elements  for a person-centered plan, identifying each residents preferences of dignity, privacy, choice, individuality and independence.  

Temporary service plans are being done on changes that occur and will be monitored until resolved or deemed permanent.

A new form was implemented to assist staff in alerting the nurse of changes to each residents preferences to their person-centered care.

Care plans will be monitored and reviewed quarterly and PRN by the LPN, Administrator and RN.  

3. Resident 1 was admitted to the facility in 8/2018 with diagnoses including insulin dependent diabetes and was identified with behaviors.

a. Staff reported Resident 1 would intentionally get on the floor when staff did not respond to the call system fast enough.

A Behavior Support Services Behavior Plan providing strategies and interventions for care staff to reduce Resident 1 staging falls was in place.

Progress notes indicated Resident 1 was observed to place him/herself, or was found, on the floor 20 times between 5/1/21 and 8/30/21.

There was no documented evidence of a thorough evaluation of the incidents to determine if interventions were implemented and/or effective.

b. Resident 1 was identified to have skin tears and abrasions on seven occasions following incidents of being found on the floor.

There was no documented evidence the injuries were monitored until resolved.

c. Resident 1 was sent to the emergency department twice related to low blood sugars and changes in awareness/cognition.

There was no documented evidence Resident 1 was monitored following the hospital visits.

d. Resident 1 had multiple medication changes, including insulin and psychoactive medications.

There was no documented evidence the changes in critical medications were monitored.

The need to ensure Residents 1, 2 and 3 were monitored per their evaluated needs and changes in condition were evaluated and monitored until resolved was discussed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and monitored to resolution, and failed to determine and document actions or interventions and communicate those to staff for 3 of 3 sampled residents (#s 1, 2 and 3) who had changes of condition. Findings include, but are not limited to:

1. Review of Resident 3's progress notes and nursing notes dated 6/29/21 through 8/30/21 revealed s/he was not monitored after being admitted to the facility in 6/2021.

Physician orders dated 8/2/21 indicated Fluticase Proprionate 50mcg was changed to PRN and the resident was prescribed Hydrocortizone-10 to be applied twice daily. There was no indication Resident 3 was monitored after the medication changes.

Interview with Staff 2 (LPN) on 8/31/21 confirmed facility staff did not monitor Resident 3 after moving into the facility or when his/her medications were changed.

2. Resident 2 was admitted to the facility with diagnoses including agitation.

Physician orders dated 8/5/21 directed staff to administer PRN Risperidone 0.5 mg for agitation.

During an Interview with Staff 2 on 8/31/21, she stated Resident 2 was verbally aggressive and threatened physical harm towards her including "he was going to kill me."

Resident 2 experienced a change of condition related to behaviors and the addition of a PRN behavior medication.  There was no documented evidence actions or interventions were developed and communicated to staff and no evidence the resident was monitored through resolution.

Policies are in place for monitoring residents for change of condition.  

Direct care staff receive training during staff orientation on how to idenitify and report a change of condition.  Direct care staff will report changes to facility LPN, RN or Administrator as they occur.  Both LPN and Administrator are available 24 hours a day 7 days a week.  RN will be responsible for assessing the change of condition and if further action is required.  

All staff were inserviced on monitoring and charting of New admits, change of conditions, Med changes, and ER/Hospital visits.  All shifts will monitor for 7 days with progress notes on the electronic records.   All PRN psychoactive medications have been updated with parameters for behavioral use.  Parameters also  include non-pharmaceutical interventions, before medication use.  Exempt from these non-pharmaceutical interventions are residents who are able to self direct.  All direct care staff have been inserviced on non-pharmaceutical interventions and documenting results of interventions prior to giving psychoactive medications.  

All residents in current survery were updated and approaches, parameters and interventions were incorporated into their individual records.  LPN and RN will monitor and maintain care plans and MAR's as events occur.   

Based on interview and record review, it was determined the facility failed to monitor short-term changes consistent with evaluated needs and service plan until resolution for 2 of 3 sampled residents (#s 5 and 6). This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted in 2019 and had diagnoses which included Alzheimer's dementia.

Resident 6's clinical record and charting notes, reviewed from 01/01/22 through 03/30/22, revealed the following:

* On 01/02/22, the facility initiated short-term monitoring for behaviors. However, no monitoring until resolution was documented for the change in condition.

* On 01/10/22, staff documented that the resident had a blood blister on his/her left big toe. No on-going monitoring of the injury was noted in the record.

* A chart note, dated 01/13/22, indicated the resident had a wound on his/her right toe. The record revealed no documented monitoring of the resident's wound at least weekly until resolved.

* The resident was sent to the ER on 02/14/22 and was admitted for aspiration pneumonia. S/he returned to the facility on 02/22/22. Although the facility initiated short term monitoring, the record revealed no documented monitoring of the resident's condition at least weekly until resolved.

* On 03/01/22, the resident was placed on monitoring because s/he was "slumped" at the dining table and had a decreased level of consciousness. Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved.

* On 03/03/22, staff documented that the resident injured his/her right-hand knuckle related to a fall. There was no documented treatment nor monitoring of the wound until resolved.

* On 03/16/22, progress notes indicated the resident had a wound on his/her right hand. Documentation lacked further information about the wound, including treatment and monitoring until resolved.

* Between 01/01/22 and 03/30/22, the resident had fallen 15 times. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for each fall until resolved.

Additional information was requested on 03/31/22 at 11:00 am.

On 03/31/22 at 3:00 pm, Staff 1 (Administrator) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided.

2. Resident 5 was admitted in 02/07/22.

Resident 5's clinical record and charting notes, reviewed from 02/07/22 through 03/30/22, revealed the following:

* Short-term monitoring was initiated when the resident moved into the facility on 02/07/22. However, the facility failed to monitor the resident until resolution.

* On 02/25/22, the resident reported vomiting. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the change in condition.

* The resident had falls on 02/12/22, 02/26/22 and 03/25/22. The facility failed to investigate the circumstances for each fall to determine if service-planned interventions were implemented, were effective or if new interventions were needed. Additionally, the facility failed to monitor the resident's status for the falls on 02/12/22 and 02/26/22 until resolved.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings. No further information was provided.

Policies are in place for monitoring residents change of condition.  The policy was reviewed and a new form was implemented to assist staff with alerting nursing of changes they are oberserving.  

Direct care staff continue to receive training during staff orientation on how to idenitfy and report changes of condition.  Additional inservices are scheduled for extended trainings on person-centered plans of care.  identifying changes, dignity, privacy, choice, individuality, and independence. RN will be responsible for assessing the change of condition and if further action is required.  

Inservices are scheduled for charting and documentation from beginning to resolved.  From short term charting, to change of condition, wound cares, and behaviors.  

Fall preventions have been updated and a new alarm system was implemented as coordinated with Hospice services.  Bed and chair alarms will continue to be used for residents who are at risk for falls.  Each fall will be investigated for the circumstances of the fall and it will be determined if service plan interventions need to be inplemented, were they effective or if new interventions are needed.  

LPN and Administrator are on call 7 days a week 24 hours a day to be contacted of any and all changes.  

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4 moved into the facility in 2019 and had diagnoses which included high blood pressure.

Physician orders and MARs, reviewed from 03/01/22 - 03/30/22, revealed the following orders were not followed:

* Resident 4 had an order for Amlodopine 10 mg daily for high blood pressure. Staff were to hold the medication if the pulse was less than 50, systolic BP (top number) was less than 100 or diastolic (lower number) was less than 60. Documentation on the MAR revealed 12 occasions when the diastolic was less than 60 and the medication was not held.

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/30/22 at 3:00 pm. They acknowledged the findings. No further information was provided.

All medications with parameters were reviewed and updated.  An individual one/one inservice was given to each Med-Tech regarding parameters for Hypertension medications. Staff was instructed if vitals are below the parameters as ordered by physician, to document vitals, hold medications, recheck vitals within the hour, and contact nurse. If above the parameters, document those vital signs, give medications, recheck vitals and contact nurse. Staff was instructed to never leave the MAR blank, always chart reasons for not giving medications. LPN and RN will be responsible for montoring that parameters are being followed and charting is accurate.

2. Resident 1 was admitted to the facility in 8/2018 and was identified to have behaviors.

Resident 1 had a physician's order for Risperidone 0.25 mg as needed for behaviors. Resident 1's 8/1/21-8/27/21 MARs were reviewed.

The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 1 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication.

The need to ensure there were resident-specific descriptions of behaviors and non-drug interventions for staff to attempt prior to the administration of psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications and clear direction for the specific reasons for the use of the psychotropic medication for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications to treat behaviors. Findings include, but are not limited to:

1.  Resident 2 had a physician's order for Risperidone 0.5 mg as needed for behaviors. The medication was administered on 8/11/21 and 8/12/21.

The facility failed to ensure there were specific parameters for staff describing what behaviors Resident 2 expressed that would require medication. There were no non-pharmaceutical interventions on the MAR for staff to attempt prior to administering the medication.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

All PRN psychoactive medications have been updated with parameters for use.  Parameters describe  behaviors for use such as:  exit seeking, threatening staff, angry outburst, false believes, uncorporative, throwing themselves on the floor.  Parameters also include non-pharmaceutical interventions such as: checking for pain/discomfort, using the restroom, gardening outside, going for a walk, calls to family and friends, one/one visits, working on small appliances  etc. before use of medications.  

All direct care staff have been inserviced on non-pharmaceutical interventions and documenting results of interventions prior to giving psychoactive medications.  

All residents in current survery were updated and approaches, parameters and interventions were incorporated into their individual records.  

LPN, RN and Administrator will montitor records weekly.

Based on interview and record review, it was determined the facility failed to follow parameters prior to administering a PRN psychoactive medication for 1 of 2 sampled residents (#5) reviewed for PRN psychoactive use. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the facility in 02/2022 and was receiving hospice services as of the re-visit survey.

Resident 5 had an order for Lorazepam 0.5 mg ½ tablet every two hours as needed for anxiety. Parameters for administration included notifying hospice prior to giving the medication.

Review of the clinical record and MAR, from 03/01/22 through 03/30/22 revealed eight occasions when staff gave the PRN Lorazepam without notifying hospice prior to administration.

During an interview with Staff 9 (MT) on 03/30 22 at 3:40 pm, she reviewed the computer MAR and acknowledged staff had not followed parameters and notified hospice prior to administering the medication.

The need to ensure parameters were followed for PRN psychoactive medication was reviewed with Staff 1 (Administrator) and Staff 2 (LPN) on 03/31/22. They acknowledged the findings.  

All PRN psychoactive medications have been updated with parameters for use. Hospice was consulted and phyisican and RN reviewed their residents medications and clarified orders for administration. Med-techs will alert hospice on administration of all prn medications if directed by hospice.

Med-techs were inserviced and they reviewed parameters and non-pharmaceutical interventions before administering psychoactive medications.

All residents in current survey were updated and parameters were reviewed by Hopsice physician.  

LPN, Hospice team and RN will be responsible for assuring medications are given under the parameters prescribed by physician.  

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 7, 10 and 11) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 8/31/21.

Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities.

The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Current Staff will have completed their six hour dementia training on or before October 30th.

All new and incoming staff will have to complete their 6 hour dementia training prior to beginning job responsibilities.

Yearly competencies will be conducted to evaluate care needs and abilities learned from trainings.

Care trainings will be done through Oregon Care Partners, Relias or licensed dementia training professional.  

Records, inservices and training information will be monitored and maintained by LPN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired caregiving staff (#s 7, 10 and 11) demonstrated satisfactory performance in all job duties, and 2 of 2 (#s 7 and 11) were certified in First Aid and trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 8/31/21.

1. There was no documented evidence Staff 7 (MT), hired 6/2/21, Staff 10 (MT), hired 6/7/21, and Staff 11 (CG), hired 7/22/21, had demonstrated competence in providing assistance with ADLs within 30 days of hire.

2. There was no documented evidence Staff 7 and Staff 10 had demonstrated competence in medication administration. Staff 2 (LPN) immediately completed and documented medication pass training, including demonstration of competence.  

3. There was no documented evidence Staff 7 and Staff 11 had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

First Aide and Abdominal thrust will be completed on all current staff who are not licensed on or before October 30th.  All new and incoming staff will be requred to have First aide and abdominal thrust before being allowed to work on floor with residents.

All current staff have completed and demonstrated their ADL competencies.  All Med-staff have demonstrated-completed their skills for delegations.  

All new and incoming staff will have their 30 day competencies completed within their first 30 days of employment.

LPN, Administrator will monitor, complete and maintain records for all employee's.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 6 and 9) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records for the Year 2020 were reviewed on 8/31/21.

Staff 6 (MT), hired 4/29/09, and Staff 9 (MT), hired 6/9/03, failed to have documented evidence of completing 12 hours of required in-service training.

There need to ensure staff completed 12 hours of on-going training, including 6 hours related to dementia, was reviewed with Staff 1 (Administrator) and Staff 2 (LPN). They acknowledged the findings.

Monthly inservices will be scheuled through the RN, LPN or scheduled through Oregon Care Partners , Relias or a certified professional to complete each staff members yearly requirement for their ongoing training needs.

All staff will be required to have the six hour dementia training prior to working with residents on the floor.

Records, inservices and training information will be monitored and maintained by LPN and Administrator.

Based on interview and record review, it was determined the facility failed to conduct fire drills and failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

Review of fire drill records dated 2/24/21 through 8/31/21 revealed no documented evidence fire drills, including all required components, were conducted every other month.

Review of safety committee meetings dated 2/1/21 through 7/31/21 determined the facility did not provide fire and life safety training to staff on alternating months.

The need to ensure the facility conducted fire drills and provided fire and life safety instruction to staff on alternating months was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Fire drill policies and procedures were updated and reviewed.  A fire drill and fire life safety inservice has been completed for current month and a schedule made to assure we stay in complience with the rules or OAR 411-054-0090 fire and life safety : drills and instructions.

Fire drills will be conducted monthly, with monthly life and safety inservices to coincide with monthly staff meetings and nursing trainings.

Fire drills will be done on alternating shifts, alternate locations within the building.  It will include but not limited to: dates, times, escape routes, any problems encountered, number of residents evacuated and staff members on duty.    

Maintenance will maintain all records and provide copies for administrator to attach to all current staff members inservice records.

Based on interview and record review, it was determined the facility failed to ensure alternate routes during fire drills were used and new residents were being instructed on fire and life safety procedures within 24 hours of admission. Findings include, but are not limited to:

1. Review of fire drill records revealed the facility conducted fire drills in the same location on 2/24/21 and 5/6/21 and used the same evacuation route.

2. Interview with Staff 1 (Administrator) on 8/31/21 revealed the facility did not provide fire and life safety procedures to new residents within 24 hours of admission.

The need to ensure the use of alternate routes during fire drills and new residents were instructed on fire and life safety procedures within 24 hours of admission was discussed with Staff 1, Staff 2 (LPN) and Staff 3 (Maintenance Director) on 8/31/21. They acknowledged the findings.

Life and safety inservice training was reviewed and updated.  A new scheduled was adopted for monthly life and fire training inservices including but not limited to:  Avoiding Hazards, dangerous substances, sharp objects, slippery floors, water temperatures,and fire prevention.  

All new residents will be instructed about the facilities fire and evacuation process and procedures within 24 hours of admission and annually.  

All records and training inservices will be stored with maintenance as well as administrator.

All new current residents have been instructed and inserviced on evacuation process, fire drill policies, and general life safety information.

Administrator will assure all information goes into resident records as drills and new admission occur.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission. This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* There was no documentation of fire and life safety training provided to residents within 24 hours of move-in.

The need to ensure residents received fire and life safety training within 24 hours of admission was discussed with Staff 1 (Executive Director) on 03/30/22 at 1:45 pm. She acknowledged the findings. No further information was provided.

Nyssa Gardens has implemented a fire and life safety form that addresses the facilities fire and evacuation process and procedures. This information is presented to the resident within 24 hours of admission and annually. All Service plans have been updated concerning fire and life safety. A map of the facility was placed in all resident rooms indicating individual and personalized fire routes, staging areas and exits that each resident would follow in an emergency situation.  

Staff has been inserviced on updated care plans, room maps and forms.

Continued trainings are ongoing.

Maintenance department, LPN and Administrator will be responsible for assuring fire evacuation systems are in place within 24 hours of admittance and completed yearly.  

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

Refer to C 252, C 260, C 270, C 330 and C 422.

Systems that had been implemented after the 2021 survey, were found not to be effective. The facility has reviewed, implemented new forms, approaches, and inservice trainings for all staff as well as residents.  The facility has been able to increase staffing, along with coordinating care with outside providers.  

Facility will continue to strive for compliance with all rules and regulations, providing a safe environment where each resident will be treated with dignity, privacy, choice, individuality and independence. Each department will be responsible for assuring compliance with all state and federal regulations. Administrator, RN and LPN will continue to provide all current rules and guidelines to assure compliance is enforced.  

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

During an environmental tour on 8/30/21, the surveyor measured water temperatures in three occupied resident units. Water temperatures exceeded 120 degrees Fahrenheit up to 126.8 degrees.

The need to ensure hot water temperatures were between 110 and 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) and Staff  2 (LPN) on 8/30/21. They acknowledged the findings.

All four water heaters are now back in working ordered and temperatures were set at levels to conform to the building codes of the facility.  

Water tempertures will be monitored each week, using different locations and  rooms within the building.  Temperatures will be taken from sinks, showers, kitchen area, bathrooms, etc.

All tempertures will be documented and kept on a temperature log and maintained through maintenance weekly.

Temperatures will remain within the 110-120 degrees fahrenheit.  

Maintenance will monitor and maintain all records.

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 entered the courtyard. Findings include, but are not limited to:

The facility was toured on 8/30/21. Exit doors to the courtyard were observed without an alarm system in place to alert staff of people entering or exiting the courtyard.

The need to ensure exit door alarms or other acceptable system was in place to alert staff when residents entered the courtyard was discussed with Staff 1 (Administrator) and Staff 2 (LPN) on 8/31/21. They acknowledged the findings.

Exit doors to the inside court yard have now been installed with alarm systems to alert staff when residents are entering and exiting court yard area.  

Alarms will checked when they sound to assure residents are safe in their enviroment.

Staff on duty will check alarms as they sound during their shift each day.