The findings of the change of ownership survey, conducted 02/12/24 through 02/15/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the first re-visit of the re-licensure survey of 02/15/24, conducted 06/03/24 through 06/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 first re-visit of the re-licensure survey of 02/15/24, conducted 11/18/24 through 11/20/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the third re-visit to the re-licensure survey of 02/15/24, conducted 01/16/25, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
MCC:Memory Care Community
mg:milligram
ml:milliliter
MT:Medication Technician
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
qd:every day or daily
qid:four times a day
QI: quality improvement
RCC: Resident Care Coordinator
RN: Registered Nurse
TAR: Treatment Administration
Record
tid: three times a day
The findings of the fourth re-visit to the re-licensure survey of 02/15/24, conducted 04/03/25, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.
Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:
Resident Council Meeting notes, dated 10/16/23 through 12/18/23, revealed the following resident concerns:
* "Residents laundry not getting done or left behind";
* "Concerns about the mail";
* "Resident stated someone may have intentionally vandalized the things outside their door (suspecting another resident)";
* "Wondering about residents getting help with their meals";
* "RA's not putting residents in bed at night (leaving in chairs and not changing into pajamas)";
* "Call lights being too long at night";
* "Worried about younger people without much experience on the night shift";
* "Staff sleeping on shift";
* "Concerns about family members working together";
* "Laundry not being done in a timely manner";
* "Laundry being mixed up";
* "Piano guy making some people uncomfortable";
* "Worried about wheel chairs being driven"; and
* "Wanted to discuss doing fire drills for residents who might not know what to do in an emergency".
There was no documented evidence the concerns identified during the meetings had been addressed, responded to, or resolved.
On 02/13/24, the survey team conducted a group interview with seven alert and oriented facility residents. Multiple members of the group stated the Administrator did not consistently provide feedback to resolution when complaints/suggestions were brought to her attention.
In an interview on 02/15/24 at 10:25 am Staff 1 (ED) said resident concerns or suggestions were discussed during stand up meetings with department heads and, if needed, during the monthly all staff meetings. She would respond to individual complaints and follow up with resolution but acknowledged the lack of documented follow-up or response to complaints or suggestions from resident council meetings.
1.) Review of Grievance Policy and Procedure with update to the grievance binder and notification to residents on process and location. Review of Resident Councel Meeting Notes with response to address all concerns and grievences noted. All Resident Cuncel grievances will be logged in the grievance binder and follow up and implementation of plan towards resolution.
2.) Policy and Procedure will be implemented and followed to include Grievance policy and log with review of grievances weekly, record actions taken on the grievance form with follow up within five days from date of notification to the ED. All grievances and/or complaints will have a written response within 30 days. Resident Councel meeting notes to be reviewed upon receipt with responses to items addressed provided to the Counsel President within seven days and items will be logged into the grievance binder with follow up per policy.
3.) The resident grievance log will be checked weekly, resident counsel meeting notes will be reviewed monthly with responses and action plans per policy.
4.) It is the responsibility of the Executive Director to ensue the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. This is a repeat citation. Findings include, but are not limited to:
Resident Council Meeting notes, dated 05/20/24, revealed the following resident concerns:
* "Laundry issues still happening not being return in a timely manner - having to look for it - sometimes several days...";
* "Lost a set of sheets a while ago and never found";
* "Broken washers too often";
* "Bedding isn't changed and washed often enough";
* "Any possibility of lowering the volume of the walkies and also not broadcasting private info";
* "Please tone down noises at shift change!!!";
* "Please don't eat food off resident's trays"; and
* "Air doors to get flies out of dining area. Ongoing problem!".
In an interview on 06/04/24 at 1:05 pm, Staff 15 (ED) acknowledged the lack of documented follow-up response to complaints or suggestions from Resident Council Meetings. She stated her plan was to have a monthly Town Hall meeting with residents, about one week after Resident Council meetings to address any concerns or suggestions.
The need to ensure there were effective methods of responding to and resolving resident complaints was discussed with Staff 14 (Vice President of Operations) and Staff 15 on 06/05/24. The findings were acknowledged.
1) Review of the Grievance Policies and Procedures. Residents will be reminded of the availability and location of the Grievance Binder. ED will implement monthly Town Hall meetings to be conducted approximately 1 week after monthly Resident Council meetings to discuss resident concerns/suggestions that were brought up in the Resident Council meeting.
2. Policy and Procedure will be implemented and followed to include a twice weekly review of the Grievance Binder by the ED. All grievances/complaints entered into the Grievance Binder will have a written response within 10 days. Responses will be logged into the binder. Resident Council meetings will be followed by a monthly Town Hall meeting to discuss concerns. Written Resident Council notes and written Town Hall notes will be entered into the Grievance Binder.
3) The Resident Grievance Binder will be checked twice weekly. Resident Council notes will be reviewed monthly and responded to during the Monthly Town Hall meeting.
4) It is the responsibility of the ED to ensure corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (# 1) was given an informed choice and opportunity to select or refuse service related to meal service. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 09/2022 with diagnoses including pulmonary hypertension due to left heart disease and Type 2 diabetes.
The resident's progress notes, dated 11/01/23 through 02/12/24, and the service plan, dated 01/09/24 were reviewed.
On 11/01/23 progress notes stated "Resident would not get out of bed for lunch. Was telling the RA's [resident assistant] that '[s/he] was sick and dying and deserves a tray in [his/her] room.' This MT explained part of [his/her] care plan is to eat in the dining room. This MT also asked what makes resident think [s/he] is sick-[s/he] stated [s/he] just is. Resident refused to get up and refused to eat." Five minutes later Resident 1 asked for a supplement drink.
On 02/12/24 at 4:03 pm Witness 1 notified this surveyor that s/he visited Resident 1 on 02/12/24 and there were two signs hanging in the apartment that said "NO TRAYS. RESIDENT GOES DOWN TO DINING ROOM FOR ALL MEALS". The signs were removed by Witness 1 and Staff 1 (ED) was notified.
On 02/13/24 at 12:35 pm this surveyor asked Resident 1 where s/he wanted to eat meals. S/he stated, "Sometimes I want to eat in my room, like if I am watching a movie, but they won't let me. I'd like to be able to but they will say I'm nuts if I want to eat up here".
The need to ensure residents were given an informed choice and opportunity to select or refuse service was discussed with Staff 1, Staff 2 (Health Services Director, RN) and Staff 4 (RCC) on 02/15/24 at 9:30 am. They acknowledged the findings.
1.) Resident #1 will have his/her Service Plan updated to reflect resident's preferences related to dining and provide clear instruction to staff.
2.) All staff will complete Oregon Care Partners/Relias trainings: Resident Rights in Assisted Living and Home and Community-Based Services and Settings (HCBS) and Individually-Based Limitations (IBL).
3.) Required trainings specific to correction will be audited weekly until all staff completion. Service Plans will be reviewed quarterly to ensure Resident Rights are respected and directed appropriately.
4.) It is the responsibility of the RCC and ED to ensure corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements for 1 of 1 sampled resident (#4) who was recently admitted to the facility. Findings include, but are not limited to:
Resident 4 was admitted to the facility in 01/2024 with diagnoses including: mild cognitive impairment, anxiety with depression and heart disease.
Review of the initial evaluation dated 01/04/24 revealed the following elements were missing:
* Interests, hobbies, and social and leisure activities;
* Mental Health issues including: history of treatment and effective non-drug interventions;
* Personality: including how the person copes with change or challenging situations;
* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort; and
* Recent losses.
The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (ED) and Staff 4 (RCC) on 02/15/24. They acknowledged the findings.
1.) Resident #4 Evaluation and Service Plan will be updated to reflect all areas identified: Interests, hobbies, and social leisure activities; Mental Health issues including: history of treatment and effective non-drug interventions; Personality: including how the person copes with change or challenging situations; Pain: pharmaceutical and non-pharmaceutical interventions, including how the resident expresses pain or discomfort; and Recent Losses.
2.) The RCC will complete the Oregon Care Partners/Relias trainings: The Role of the Service Plans and Service Plans for Assisted Living Facilities. The RCC will have review of OAR 411-054-0034 (1-6) with the ED and signed aknowledgement of understanding will be maintained in RCC's file.
3.) The area needing correction will be evaluated weekly until completion and then quarterly and will new move ins.
4.) It is the responsibility of the RCC and ED to ensure the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure the initial move-in evaluation contained all required elements for 1 of 1 sampled resident (#8) who was recently admitted to the facility. This is a repeat citation. Findings include, but are not limited to:
Resident 8 was admitted to the facility in 04/2024 with diagnoses including: aortic valve stenosis, chronic pain, and chronic kidney disease.
Review of the initial evaluation revealed the following elements were missing:
* Spiritual, cultural preferences and traditions;
* Decision making abilities;
* Personality: including how the person copes with change or challenging situations;
* Fluid preferences;
* Emergency evacuation ability; and
* Environmental factors that impact the resident's behavior including but not limited to: noise, lighting, room temperature.
The need to ensure the initial evaluation included all of the required elements was discussed with Staff 14 (ED) on 06/05/24. She acknowledged the findings.
1) Resident #8 Evaluation and Service Plan will be updated to reflect all areas identified: Spiritual, Decision making abilities, Personality,Fluid preferences, Emergency evacuation ability and Environmental factors impacting behaviors.
2) Person that completed Evaluation and Service Plan for resident #8 was released from the community. New RCC completed Oregon Care Partners and Relias training including: The Role of Service Plans and Service Plans for Assisted Living Facilities. RCC also reviewed OAR 411-054-0034 (1-6). A signed aknowledgement of understanding is in the RCC's employment file.
3) The area needing correction will be evaluated weekly until completion and then quarterly. It will be completed with all new move ins.
4) It is the responsibility of the RCC and ED to ensure the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 1 of 1 sampled resident (# 1) who experienced a significant change of condition. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 09/2022 with diagnoses including pulmonary hypertension due to left heart disease and Type 2 diabetes.
The resident's 09/01/23 through 02/12/24 weight records, progress notes, dated 11/01/23 through 02/12/24, and the service plan, dated 01/09/24, were reviewed.
On 10/23, Resident 1 weighed 247 pounds. On 01/24, the resident weighed 218 pounds, which was a 29 pound weight loss. This constituted a severe weight loss of 11.7 % in three months.
On 02/14/24 at 11:00 am Staff 2 (Health Services Director, RN) stated that residents were weighed on the seventh of every month and the residents' weights were calculated to identify any significant weight losses or gains. She acknowledged she missed identifying Resident 1's significant weight loss. There was no documented evidence there was an RN assessment which included findings, resident status, and interventions made as a result of this assessment.
Resident 1's weight during the time of the survey was 217 pounds. No additional significant change had occurred.
The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 on 2/15/24. They acknowledged the findings.
1.) Resident #1 will be assessed by the RN with change of condition for significant weight loss assessment completed and notifications to residents MD for interventions/instructions. Residents Service Plan will be updated to identify change of condition with interventions and care needs updated and instructed clearly.
2.) Residents weights will be checked/monitored the first week of every month and as ordered by providers. Weigth variances will be reviewed by the RCC and RN to identify significant changes with assessments completed by the RN as required for COC.
3.) The area needing correction will be evaluated monthly and as needed.
4.) It is the responsibility of the RCC, RN and ED to ensure the corrections are completed and monitored.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control for protocols to provide a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 2) and have an "Infection Control Specialist" qualified by education, training and experience or certification. Findings include, but are not limited to:
1. Resident 2 was admitted to the facility in 03/2021 with diagnoses including multiple sclerosis.
Observations and interviews of the resident and interviews with staff from 02/12/24 through 02/14/24 revealed Resident 2 was bed bound and relied on two staff for incontinence care needs and repositioning.
On 02/13/24, at 1:45 pm, the surveyor observed two staff members donned gloves to provide incontinence care and a bed change for Resident 2. There was a third caregiver present with donned gloves observing for training purposes.
* One caregiver provided incontinence care for Resident 2 by wiping the perineal area with a cloth and warm water and patted dry with a paper towel.
* The second caregiver on the right side of the bed removed a soiled paper towel from the pannus area of Resident 2, wiped the area with a second cloth with warm water, patted the area dry with a paper towel, applied barrier cream to the pannus area and put a clean paper towel on the pannus area at Resident 2's request.
* Resident 2 was rolled from the left side of the bed towards the right side of the bed to remove the soiled sheet, towel and protective pad and placed a clean sheet, towel and protective pad under Resident 2, all while using the same soiled gloves.
* Resident 2 was then rolled from the right side to the left side of the bed so the clean sheet, towel and protective pad could be placed on the right side of the bed.
* Soiled gloves were removed following completion of the task.
The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 4 (RCC) on 02/15/24. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 09/2022 with diagnoses including pulmonary hypertension due to left heart disease and type 2 diabetes.
During interviews and observations from 02/12/24 through 02/14/24, Resident 1 was noted to require three person assist for all transfers and bed mobility.
a. During an ADL observation on 02/13/24 at 1:40 pm the following was noted:
* Three staff donned gloves and provided assistance to the resident to stand up from the wheelchair. One additional staff member donned gloves and secured the walker and was not involved in providing incontinent care.
* The three remaining staff assisted in removing his/her soiled incontinence brief and replaced the wheelchair with the bedside commode.
* One staff stood behind the resident and provided perineal care with wipes following a bowel movement and applied barrier cream to his/her buttocks.
* The same three staff touched a clean incontinence brief, replaced the bedside commode with the wheelchair, adjusted the clothing, and touched the television remote, all while using the same soiled gloves.
* The staff members removed the soiled gloves and performed hand hygiene after leaving the resident's room.
3. Upon entrance to the facility on 02/12/24, the facility's designated "Infection Control Specialist" and documentation of completed specialized training in infection prevention was requested and received. Records indicated that Staff 5 (Environmental Services Director) was the facility's designated "Infection Control Specialist". The documentation showed the training was completed on December 27, 2022.
On 02/13/23 at 11:30 am, Staff 5 acknowledged he did not have a health professional education background or experience in infection control as a health inspector.
The need to ensure establishment and maintenance of infection prevention control protocols and compliance with the facility's designated "Infection Control Specialist" qualification was discussed with Staff 1 (ED), Staff 2 (Health Services Director, RN) and Staff 4 (RCC) and on 02/15/24 at 9:30 am. They acknowledged the findings.
1.) Resident #1 and Resident #2: All direct-care staff will be provided training on infection prevention and control protocols to include the proper use of PPE more specific to appropriate use and changing of gloves. The RN is qualified by education, training and experience and will complete the training: Infection Control Specialist as the designated individual to maintain this role.
2.) The Infection Control Specialist will ensure ongoing trainings and random observations to ensure proper infection prevention and control protocols are maintained. All trainings and observations will be documented in employee files.
3.) The area needing correction will be evaluated weekly until completion of trainings and then quarterly with quality assureance audits.
4.) It is the responsibility of the RCC, RN and ED to ensure the corrections are completed and monitored.
Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control for protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (# 7) and have an "Infection Control Specialist" qualified by education, training and experience or certification. This is a repeat citation. Findings include, but are not limited to:
a. Resident 7 was admitted to the facility in 08/2020 with diagnoses including cerebrovascular accident.
Observations and interviews of the resident and interviews with staff from 06/03/24 through 06/05/24 revealed Resident 7 was chair bound and relied on two staff for incontinence care needs and repositioning.
On 06/04/24 at 10:19 am, the surveyor observed Staff 7 (CG) and Staff 26 (MT) don gloves to provide incontinence care and to assist in the morning routine for Resident 7.
* Staff 26 removed a soiled comforter, bedding, and pillow case and placed in in the resident's hamper and did not change gloves or perform hand hygiene after this task.
* The two staff members assisted the resident to transfer from lying down to a seated position. Then, a transfer to the wheelchair and subsequently to the toilet was completed.
* The two staff members assisted Resident 7 in removing the soiled clothing and brief and failed to perform glove change or hand hygiene after this task.
* Staff 7 wet a washcloth in the sink without glove change and handed it to Staff 26. After this, Staff 7 changed gloves without performing hand hygiene.
* Staff 26 assisted the resident in cleaning his/her skin while the resident was seated on the toilet. Staff 7 exited the resident's apartment with the hamper.
* Staff 7 returned to the apartment and donned gloves without performing hand hygiene prior to reheating the resident's breakfast.
* Staff 26 performed perineal care, while Staff 7 assisted the resident for stability.
* Both staff placed a clean brief on the resident without performing hand hygiene or glove change prior to task.
* Both staff then assisted the resident into clean clothes, adjusted the clothes, transferred him/her from the toilet to the wheelchair, and touched the wheelchair handles, all while using the same soiled gloves.
* The staff members removed the soiled gloves and performed hand hygiene after leaving the resident's room.
b. Upon entrance to the facility on 06/03/24, the facility's designated "Infection Control Specialist" and documentation of completed specialized training in infection prevention was requested and received.
In an interview on 06/05/24 Staff 15 (ED) was identified as the facility's Infection Control Specialist. She stated the facility's plan was to have multiple people take the required training, with the RN taking over the Infection Control Specialist position for the facility.
The facility lacked documented evidence Staff 4 had completed the required specialized, Department-approved training in infection prevention and control protocols for a Residential Care Facility infection control specialist.
The need to ensure establishment and maintenance of infection prevention control protocols and compliance with the facility's designated "Infection Control Specialist" qualification was discussed with Staff 14 (Regional Vice President of Operations) and Staff 15 on 06/05/24. They acknowledged the findings.
1)All Direct Care staff will be provided training on infection prevention and control protocols including the proper use of PPE, focusing on the proper use and changing of gloves. RN was recently hired and is qualified by education and experience. RN will complete the 4 hour Infection Control Specialist training and will be the designated Infection Control Specialist.
2) The Infection Control Specialist will ensure ongoing trainings and complete unscheduled observations/inspections to ensure proper infection prevention and control protocols are being maintained. All trainings and observations will be documented in the employee file.
3) The area needing correction will be evaluated weekly until completion of trainings and then quarterly with Quality Assurance audits.
4) It is the responsibility of the RN, RCC and ED to ensure corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#6) whose orders were reviewed. Findings include, but are not limited to:
Resident 6 was admitted in 12/2019 with diagnoses which included dementia and major depressive disorder with psychotic features.
Review of the resident's clinical record revealed the following:
Resident 6 had an order for olanzapine ODT 5 mg tab to be given as needed for severe agitation/mood.
Resident 6's progress notes between 05/06/24 and 05/30/24 documented behaviors where staff attempted multiple non-pharmacological interventions that were ineffective, but no PRN was offered to the resident after each event.
The MAR, reviewed from 05/01/24 through 05/31/24, revealed staff were not administering the medication as ordered.
On 06/04/24 in an interview with Staff 25 (MT), s/he stated that they had been trained only to give a PRN to the resident when they asked for it.
In an interview on 06/04/24 at 12:40 pm, Staff 16 (RN/Health Wellness Director) stated she was aware of this order and that it did not specify Resident 6 could self direct this PRN medication.
Failure to ensure physician orders were carried out as prescribed was discussed with Staff 15 (ED) on 06/05/24. She acknowledged the findings. No further information was provided.
1) Resident #6 MAR will be reviewed with Med Techs. Med Techs will be trained in the parameters of proper administration of PRN's by unlicensed staff after multiple non-pharmacological interventions are deemed ineffective.
2) MAR's will be reviewed by the HSD monthly and by the Pharmacy RN quarterly.
3) MAR's will be audited/evaluated weekly until completed and monthly thereafter.
4) It is the responsibility of the RCC, HSD and ED to ensure the correction is completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat residents' behaviors had non-pharmacological interventions that had been tried with ineffective results prior to administering PRN psychotropic medications for 1 of 1 sampled resident (#6) who was prescribed a PRN psychotropic. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 12/2019, with diagnoses including anxiety, depression, psychosis, and dementia with behavioral disturbance.
Review of Resident 6's MAR, dated 01/01/24 through 2/12/24, indicated the resident was prescribed the following PRN psychotropic: olanzepine 2.5 mg by mouth every day as needed for severe agitation/mood.
In an interview with Staff 2 (Health Services Director, RN) on 02/14/24 at 9:40 am it was confirmed there was no documented evidence non-pharmacological interventions were tried and found to be ineffective prior to administration of the PRN olanzepine on three occasions between 01/01/24 and 01/31/24.
The need to ensure PRN medications given to treat a resident's behaviors had written non-pharmacological interventions which had been tried with ineffective results prior to administration was discussed with Staff 1 (ED) and Staff 4 (RCC) on 02/15/24. They acknowledged the findings.
1) Resident #6 MAR reviewed with update to PRN psychtropic medications adding resident specific parameters regarding when unlicensed staff are to administer the medication and non pharmacological interventions to attempt. MAR will be adjusted to cue med tech for interventions and med tech to document interventions attempted and effectiveness.
2) MAR's will be reviewed by the HSD monthly and by pharmacy RN quarterly.
3) System will be audited/evaluated weekly until completed and Quarterly ongoing.
4) It is the responsibility of the ED, RCC and HSD to ensure correction is completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions of the device for 1 of 1 sampled resident (# 1) with two half-length side rails. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 09/2022 with diagnoses including pulmonary hypertension due to left heart disease and Type 2 diabetes.
On 02/13/24 at 12:35 pm, Resident 1's bed was observed with two half-length side rails in the up position and were secured to the bed.
During an interview on 02/13/24, Resident 1 stated s/he used the side rails to help with positioning and safety when in bed.
On 02/13/24 a side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.
On 02/14/24 the RN completed a siderail assessment that included documentation related to less restrictive alternatives attempted prior to use and an interim service plan that included instruction to caregivers on correct use and precautions.
The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 (ED), Staff 2 (Health Services Director, RN) and Staff 4 (RCC) on 02/15/24 at 9:30 am. They acknowledged the findings.
1.) Resident #1 will be assessed by the RN for use of bilateral half length side rails. The service plan will be reviewed and updated to ensure documentation of prior attempts with alternative devices with less restrictive qualities, clear instruction for caregivers on correct use and precautions related to the use of the device, as well as clear instructions and precautions for the resident.
2.) Ensure implementation of service planning team to include the participation of the HSD for review of required areas specific to Nursing Services and Assesssments. Required Assessment/Sub-Assessments will be completed quarterly with re-evaluations and with Change of Condition.
3.) Implementation of service planning team meetings to identify and ensure timely completion of re-evaluations, assessments and sub assessments accurately will be evaluated weekly for 60 days and continued monthly and as needed.
4.) It is the responsibility of the ED and HSD to ensure that corrections are monitored and completed.
Based on interview and record review, it was determined the facility failed to develop a staffing plan to meet the scheduled and unscheduled needs of the residents based on care minutes calculated by their ABST. Findings include, but are not limited to:
The facility's ABST calculations, resident ABST data entries and the facility's staffing plan were reviewed on 02/13/24 and 02/14/24.
Review of the record and interviews with Staff 1 (ED) revealed the following:
* Residents from a separately licensed RCF were included in the ALF ABST;
* It was unclear how many minutes it took a staff person to complete a required care element. The administrator was unable to address if numbers shown on the ABST report were points or minutes.
*The facility was not determining the facility staffing plan with an ABST as required by rule.
Interviews on 2/13/24 and 2/14/24 were conducted with Staff 1 and she acknowledged one staffing plan was created for residents in the ALF and RCF. No documented evidence of an exception for creating one staffing plan was provided.
The need to ensure ABST resident entries were accurate and staffing calculations were used to develop and implement a staffing plan to meet resident needs was discussed with Staff 1 on 02/15/24. No further information was provided.
1.) The current ABST reporting system has been updated with separation from licensed RCF. Additional training/guidance provided to the ED for clarification of ABST system and calcualtions of minutes to hours required daily to ensure appropriate staffing ratios.
2.) The individual systems will be maintained seperately and appropriately by the identified responsible parties. The ED will provide oversite of the ALF's ABST and the Administrator will provide oversite of the RCF's ABST with clear separation of resident's, acuities and time parameters for staffing ratios required for each individually licensed community.
3.) The area needing correction will be evaluated weekly until completion and then monthly and as needed.
4.) It is the responsibility of the RCC and ED to ensure corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to complete an Acuity Based Staffing Tool (ABST) assessment for each resident, reviewed for each resident no less than quarterly, and to use the results to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings include, but are not limited to:
The facility's ABST calculations, resident ABST data entries, and the facility's staffing plan were reviewed on 06/04/24 at 12:25 pm with Staff 14 (Regional Vice President of Operations) and Staff 15 (ED). The following was identified:
a. One unsampled resident was not included in the ABST.
b. One unsampled resident was included in the ABST but was no longer a resident in the facility.
c. Four unsampled residents' ABST assessment did not show evidence of being updated at least quarterly.
During an interview on 06/04/24 at 12:30 pm, Staff 14 stated the facility was using the ABST to develop and update the facility's staffing plan. However, the data in the ABST was not up to date to accurately reflect the amount of staff time needed to meet the 24-hour scheduled and unscheduled needs of the residents.
The need to ensure an ABST assessment was completed for each resident, reviewed for each resident no less than quarterly, and the tool was used to develop and update the facility's staffing plan was discussed with Staff 14 and Staff 15 on 06/05/24. They acknowledged the findings.
1) The ABST was reviewed for accuracy and updated to reflect the current population in the ALF as well as the RCF. ABST will be compared to the resident roster and monitored for accuracy.
2) Resident ABST assessments will be updated at least quarterly and reviewed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needs of the residents.
3) The area needing correction will be evaluated/updated weekly until completion and then monthly and/or as often as needed.
4) It is the responsibility of the RCC, RCF Administrator and ED to ensure corrections and updates are completed and updated.
Based on interview and record review, it was determined the facility failed to implement a proprietary ABST that was Department-approved. This is a repeat citation. Findings include, but are not limited to:
On 11/19/24 at 10:00 am the facility's proprietary ABST was reviewed with Staff 15 (ED) and Staff 10 (RCF Director). There was no documented evidence the Department approved the facility's proprietary tool. No additional information was provided.
The need to ensure the facility implemented a Department-approved ABST was discussed with Staff 15 on 11/20/24 at 2:30 pm. She acknowledged the findings.
1. All residents have been transferred over to the ODHS Acuity Based Staffing Tool as of 12/03/2024.
2. Residents that move in, move out or pass away will be added or deleted on the ODHS ABST. Resident assessments will be updated at least quarterly or upon a change of condition and the ABST will be reviewed and updated as needed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needsof the residents. The resident roster will be cross referenced with the ABST roster at least twice a month to ensure accuracy of the number of residents.
3. The area needing correction has been transferred over to the ODHS ABST and will be monitored as often as needed based off of resident assessments, changes of conditions and needs.
4. It is the responsibility of the RCC, RCF Administrator and the ED to ensure the corrections and updates are completed and updated.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan for one sampled resident (#13) and multiple unsampled residents, and failed to develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. Findings include, but are not limited to:
On 11/19/24 at 10:00 am, the facility provided a copy of the proprietary ABST for the current residents and the following was identified:
* Five residents, including one sampled resident (#13), had not been entered;
* Three residents had been entered into the facility's ABST, but were not in the facility at the time of the survey; and
* The proprietary ABST used by the facility did not develop a staffing plan for each shift.
On 11/19/24 at 11:25 am, Staff 15 (ED) acknowledged the facility's ABST did not have all of the current residents entered, several of the residents were no longer in the building, and therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents that could be used to develop the facility staffing plan.
During an interview on 11/20/24 at 11:00 am, Staff 15 acknowledged the ABST used by the facility did not develop a staffing plan for each shift to meet the scheduled and unscheduled needs of all the residents.
The need to ensure the facility's ABST included all residents in order to determine appropriate staffing levels for the facility and to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 15 and Staff 10 (RCF Director) on 11/20/24 at 2:30 pm. They acknowledged the findings.
1. All residents have been transferred over to the ODHS Acuity Based Staffing Tool as of 12/03/2024.
2. New residents that move in will be added to the ODHS ABST. Resident assessments will be updated at least quarterly or upon a change of condition and the ABST will be reviewed for accuracy to reflect the amount of staff needed to meet the 24-hour scheduled and unscheduled needs of the residents. In addition to at the time of move in or upon a change of condition, the ABST will also be updated to reflect a resident death or a move out.
3. The area needing correction has been transferred over to the ODHS ABST and will be monitored as often as needed based off of resident assessments, changes of conditions and needs as well as move ins, move outs and deaths. The resident roster will be cross referenced with the ABST roster at least twice a month to ensure accuracy of the number of residents.
4. It is the responsibility of the RCC, RCF Administrator and the ED to ensure the corrections and updates are completed and updated.
Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff were providing to each resident as outlined in each individual service plan for multiple unsampled residents and failed to develop an accurate staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents. This is a repeat citation. Findings include, but are not limited to:
On 01/16/25 at 11:00 am, Staff 15 (ED) provided the surveyor with a list of the current residents residing in the facility. The facility's ABST was reviewed and compared to the current resident list and the following was identified:
* Two unsampled residents had not been entered into the ABST;
* One unsampled resident's ABST information was incomplete; and
* One resident had been entered into the facility's ABST but was not in the facility at the time of the survey.
On 01/16/25 at 11:30 am, Staff 15 acknowledged the facility's ABST did not have all the current residents entered, one of the residents was no longer in the building, and therefore, the tool did not accurately determine the correct amount of staff time required to provide care to the residents and could not meet the scheduled and unscheduled needs of the residents.
The need to ensure the facility's ABST included all residents to determine appropriate staffing levels for the facility to meet the 24-hour scheduled and unscheduled needs of the residents was discussed with Staff 15 on 01/16/25. She acknowledged the findings.
1. The ED and AED will review the ABST along with the current census on a daily basis and cross reference for accuracy. Any discrepancies will be remedied immediately.
2. BOM and Sales Director will communicate new move-ins/outs with ED and AED. Once communicated, ABST will be updated to reflect changes. RCC and AED will review ABST and update upon changes of condition as well as based upon needs and services of current residents.
3. This area will be evaluated on a daily basis through review of the ABST along with communication from the SD, BOM, AED, RCC and ED.
4.It will be the responisbility of the ED, AED and RCC to ensure completion and accurate montoring.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure pre-service infectious disease prevention and dementia care training had been completed prior to providing direct care to residents for 1 of 3 newly hired staff (#8). Findings include, but are not limited to:
The facility's training records were reviewed with Staff 3 (Business Office Manager) on 02/13/24. The following was noted:
a. Staff 8 (MT) hired 10/16/23 lacked documented evidence pre-service infectious disease prevention was completed prior to providing care to residents.
b. Staff 8 lacked documented evidence pre-service dementia care training was provided prior to providing care to residents in the following areas:
* Techniques for understanding, communicating and responding to behaviors, reducing use of antipsychotics; and
* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.
Requirements for pre-service infectious disease prevention and dementia care training were reviewed with Staff 1 (ED) and Staff 4 (RCC) on 02/15/24. They acknowledged the findings.
1.) Staff #8 will be removed from the schedule pending completion of pre-service infectious disease prevention, pre-service dementia care training to include the following areas: Techniques for understanding, communicating and respondng to behaviors, reducing use of antipsychotics; and specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person centered approach.
2.) All employees will complete the onboarding process which includes completing the state required trainings prior to beginning their perspective jobs, trainings to include all identified in OAR 411-054-0070 as well as required certifications and licenses pertaining to specific job descriptions and positions.
3.) New employee orientation and training requirements completed will be evaluated weekly unitl completion and then monthly and as needed.
4.) It is the responsibility of the ED and BOM to ensure that corrections are monitored and completed.
Based on interview and record review, it was determined the facility failed to ensure pre-service infectious disease prevention training had been completed prior to providing direct care to residents for 3 of 3 newly hired staff (#s 16, 17, and 18). This is a repeat citation. Findings include, but are not limited to:
The facility's training records were reviewed with Staff 3 (Business Office Manager) on 06/04/24. The following was noted:
Staff 16 (RN/Health Wellness Director), hired 05/20/24, Staff 17 (CG), hired 04/23/24, and Staff 18 (CG), hired 04/14/24, lacked documented evidence pre-service infectious disease prevention was completed prior to providing care to residents.
Requirements for pre-service infectious disease prevention and training were reviewed with Staff 15 (ED) on 06/05/24. She acknowledged the findings.
1) Newly hired team members 16, 17 and 18 not currently in compliance with pre-service infectious disease prevention trainings will be removed from the schedule pending completion of the trainings.
2) Newly hired team members will not be on the scheduled to provide care to residents until all required pre-service trainings identified in OAR 411-054-0070 are completed as well as any required certifications and licenses pertaining to specific job descriptions and positions..
3) This area will be evaluated weekly until completion and then on an ongoing basis, every time a new team member is hired.
4) It will be the responsibility of the BOM, Staff Scheduler and ED to ensure that corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 1 of 3 long term direct care staff (#11) completed a minimum of 12 hours of in-service training annually including six hours on dementia care and 2 of 2 long term non-care staff (#s 4 and 6) completed Infectious Disease Training. Findings include, but are not limited to:
Review of the facility's training records with Staff 3 (Business Office Manager) on 02/13/24 revealed the following:
1. Staff 11 (CG) hired 11/10/21 did not have documented evidence of 12 hours of annual in-service training related to provision of care in CBC including six hours of dementia care.
2. Staff 4 (RCC) hired 08/17/17 and Staff 6 (Lifestyle Assistant) hired 06/15/18, did not have documented evidence of annual Infectious Disease Training.
The need to ensure all staff had a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including dementia care topics and that long term staff completed Infectious Disease Training was discussed with Staff 1 (ED) and Staff 4 on 02/15/24. They acknowledged the findings.
1.) Staff #11 will be removed from schedule pending completion of provisions of care in CBC to include six hours of dementia care training. Staff #4 and Staff #6 will be removed from the schedule pending completion of Infectious Disease Training.
2.) All employees are required to attend monthly in-services and employment is contingent upon attendance. The ED will maintain the annual in-service schedule assuring required topics for continued education to include disease outbreaks and infection control, provisions of care for persons in cbc setting, chronic diseases and dementia training.
3.) The required training be evaluated weekly until completion, monthly in-service training and attendance will be evaluated monthly.
4.) It is the responsibility of the ED and BOM to ensure that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to conduct and document fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:
The previous six months of fire drill and fire and life safety training records were reviewed on 02/13/23 with Staff 1 (Executive Director) and Staff 5 (Environmental Services Director). The following were identified:
a. Fire Drills:
* Fire drills were documented on 08/09/23 and 01/08/24, not every other month as required; and
* The documentation of the drills failed to include the escape route used, problems encountered, residents who failed to participate in the drills, and evacuation time-period needed.
b. Fire and life safety training for staff:
* The facility was not providing fire and life safety training for staff on alternate months as required.
The need to ensure fire drills and fire and life safety training were conducted and documented per the rules was reviewed with Staff 1 and Staff 5 on 02/13/24. They acknowledged the findings.
1) Annual calendar implemented with alternating months for Fire and Life Safety training and Unannounced Fire Drills.
2) Education provided to the ESD utilizing OAR 411-054-0090 to ensure understanding of requirements. Review of Fire Drill Records to ensure further understanding of documentation requirements to include: escape route used, problems encountered, residents who failed/refused to participate in the drill and evacuation time-period needed. Annual schedule is implemented outlining specific trainings for staff and Fire Drills alternating months.
3) Fire Life and Safety requirements will be evaluated monthly.
4) It is the responsibility of the ESD and ED to ensure that the correctios are completed and monitored.
Based on interview and record review, it was determined the facility failed to conduct fire drills every other month as required by the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:
Fire and life safety records from 04/15/24 through 06/04/24 were requested and reviewed on 06/04/24 at 11:10 am.
The facility provided documentation of fire and life safety instruction to staff on 04/10/24. However, there was no documented evidence a fire drill was conducted on the alternate month of May.
During an interview on 06/04/24 at 11:15 am, Staff 8 (Environmental Services Director) confirmed there had not been a fire drill conducted in May.
The need to ensure fire drills were conducted according to the OFC was discussed with Staff 14 (Regional Vice President of Operations) and Staff 15 (ED) on 06/04/24. They acknowledged the findings.
1) An annual calendar with scheduled unannounced fire drills and life safety trainings has been implemented.
2) Education will be provided to and reviewed with the ESD utilizing OAR 411-054-0090. Documented evidence of the fire drills will be kept. Inservice logs and training content outlines will be placed in a binder.
3) Fire Drills and Life Safety trainings will be evaluated monthly to ensure it is in compliance with OAR's.
4) The ESD and ED are responsible to ensure that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to: C154, C252, C295, C361, C370, C374, C420, and C610.
1) Multiple interventions will be utilized to ensure future compliance with C154, C252, C295, C361, C370, C374, C420 and C610. These interventions include the release of duty of team members that played a key part in non-compliance areas, re-training of team members and initiating a better system for documentation. Many rule violations were completed immediately.
2) Ongoing review of OAR's, team member trainings and detailed documentation will be implemented. Daily internal and external walks of different areas of the community property will be completed and notations made of items needing corrections. Any corrections notated will be assigned to the appropriate Department Head for compliance.
3) These areas of correction will be evaluated on an ongoing basis.
4) It will be the responsibility of the ED and individual Department Heads to ensure corrections are competed and monitored.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C361.
1. POC for C361 has been implemented and completed. The community is now using the ODHS ABST.
2. System for C361 has been corrected by the utilization of the ODHS ABST.
3. C361will be monitored on an ongoing and as needed basis.
4. RCC, Assistant ED and Executive Director will be responsible to see that C361 is monitored.
Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:
Refer to C 362.
1. To comply with C455, the AED, ED and RCC will review current census on a daily basis and cross reference for accuracy. Any discrepancies will be remedied immediately.
2. BOM and Sales Director will communicate new move-ins/outs with ED and AED. Once communicated, ABST will be updated to reflect changes. RCC and AED will review ABST and update upon changes of condition as well as based upon needs and services of current residents.
3. This area will be evaluated on a daily basis through review of the ABST along with communication from the SD, BOM, AED, RCC and ED.
4.It will be the responisbility of the ED, AED and RCC to ensure completion and accurate montoring.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair and grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:
During group interview on 02/13/24, multiple residents stated concern with litter at the front entrance of the building.
The ALF exterior grounds were observed on 02/13/24 and 02/14/24. The following were identified:
* The sidewalk parallel to the front of the building had drop offs from 2 to 3 inches in multiple areas, measured from the concrete to the grass;
* Pieces of pet food and pet waste were noted in the barkdust around the front entrance; and
* Staff were observed each morning sweeping the front entrance area, however, discarded cigarettes and refuse continued to be observed on all days of the survey.
On 02/13/24, the building's exterior was toured with Staff 1 (Executive Director) and Staff 5 (Environmental Services Director). In an interview on 02/15/24 Staff 1 acknowledged the findings.
1.)Grounds with drop off from concrete to grass were filled in and leveled by landscaping. The discarded cigarettes and refuse were cleaned up. Residents are provided escorts to designated smoking area. The entrance gardens were cleaned and new soil added in. Letter to residents encouraging/requesting cat food not be left on walkways for strays.
2.) Implementation of daily site external walk to ensure identification of debris with clean up. Services implemented and documented on ISP's for residents who smoke to provide escorts to designated smoking area. ESD communication with Landscaping Service to ensure identification and correction to level variances at walkways and flower beds.
3.) The areas needing correction will be evaluated daily/weekly until complete and sustainable. Then monthly and as needed.
4.) It is the responsibility of the ESD and ED to ensure corrections are completed and monitored.
Based on observation and interview, it was determined the facility failed to ensure grounds were kept orderly and free of litter and refuse. This is a repeat citation. Findings include, but are not limited to:
The ALF exterior grounds were observed on 06/03/24 and 06/04/24. The following were identified:
* The pillars in the front entrance to the building were covered in bird excrement;
* Bird nests were observed on top of the pillars outside building entrance; and
* Discarded cigarettes in front of the building continued to be observed on all days of the survey.
On 06/05/24, the building's exterior was toured with Staff 14 (Executive Director) and Staff 6 (Environmental Services Director). In an interview on 06/05/24 Staff 14 acknowledged the findings.
1) The pillars at front entrance have been power washed to remove the bird excrement. Bird nests have been removed and spikes will be placed in the areas of where the bird nests were located. Discarded cigarettes have been removed.
2) Spikes will be placed at the top of the pillars to prevent birds from perching and nesting on the pillars. Residents that smoke are being reminded of the smoking areas and to use proper disposal recepticles for their cigarettes. Housekeepers will monitor the area twice a day for discarded cigarettes.
3) The front entrance will be monitored and evaluated on a daily basis.
4) The ESD as well as ED are responsible to ensure that the corrections are completed and monitored for compliance
There are no detail notes for this visit.