The findings of the re-licensure survey conducted 10/31/22 through 11/02/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 11/02/22, conducted 03/02/23 through 03/03/23, are documented in this report. The survey was conducted to determine compliance with the  OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 11/02/22, conducted on 06/20/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the facility kitchen, food storage and food preparation areas on 10/31/22 noted the following needed to be cleaned and/or repaired:

* The wall near the kitchen entrance closest to the dishwashing area had an approximately three foot by one foot area of missing sheetrock, rendering the surface uncleanable;

* The shelving under the steam table had missing pieces of laminate, exposing particle board, and the surface had black matter throughout;

* Drains throughout the kitchen had blackened areas and food debris present;

* Standing mixer had dried food spills;

* Garbage cans throughout the kitchen near food prep areas were without lids;

* Items were stored on the floor in the freezer;

* The flooring near the standing ovens was cracked and chipped, rendering the surface uncleanable;

* The surface of the doors entering and exiting the kitchen were chipped and had blackened areas;

* Steam table knobs were coated with a greasy material;

* The hood had a build-up of grease;

* Free-standing freezer had an accumulation of ice and uncovered food items;

* Scoops were left in the dry storage bins;

* The back door to the kitchen was propped open without a screen to prevent insects/rodents from entering; and

* The three vents above the dishwashing area had dust and debris.

The areas in need of cleaning and repair were reviewed with Staff 6 (Grill Manager) and Staff 1 (ED) on 10/31/22 at 2:06 pm. Staff acknowledged the findings.

1.Immediate action taken included Executive Chef is coordinating the following repairs with Plant Ops Dir:

i.Wall - Executive Chef is coordinating wall repair with Plant Operations Director.

ii.Vents - Replacement of three rusted vents above dish area.

iii.Doors - Cover affected doors with wipeable surface such as plastic/plexiglas or stainless.

iv.Cracked Tiles - Coordinate repair with Plant Operations Director.

Shelving under the steam table is included on the 2023 CapEx Plan for replacement.  Cleaning items were immediately addressed. Trash can lids have been replaced . Spare lid kept onsite for back-up.

2.The  system will be corrected so this violation will not happen again by, In-servicing the Kitchen Staff on the following topics:

Team will be in-serviced on the following topic by:

i.Proper storage in freezers - no floor storage

ii.Not storing scoops in bins

iii.Not propping back door open - signage will be placed on door to remind of requirement to close door.

To ensure ongoing compliance, cleaning schedules will be revised to ensure all cited areas are included. Revised cleaning schedules will include a sign-off by the person who completed the task, and a weekly signed audit performed by the Executive Chef.

3.How often will the area needing correction be evaluated?

a.Frequency will be identified on the cleaning schedule.

b.Cleaning quality will be audited weekly be the Executive Chef

c.Items requiring repair will have a work order number attached to ensure tracking and follow up of work completion.

d.Steam table - This item will require fabrication and will require more time to complete. AOC 2/13/23

4.Executive Chef

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair and in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:

On 03/02/23 at 10:07 am the kitchen was observed to need cleaning and repair in the following areas:

* The wall in the entryway to the kitchen had holes in the drywall;

* The surface of the doors entering and exiting the kitchen and interior office doors were chipped and had blackened areas;

* The metal transition strip in the doorway to the rear exit door had a build up of a black substance on it's surface;

* The flooring near the standing ovens was cracked and chipped, rendering the surface uncleanable; and

* A light fixture near the ice machine was missing it's cover.

The areas in need of cleaning and repair were reviewed with Staff 6 (Culinary Director) and Staff 1 (ED) on 03/03/23 at 10:15 am. They acknowledged the findings.

1. Immediate action taken included getting bids from companies related to various options of floor repair and door sealing VS replacement. Work orders coordinated between Executive Chef and Plant Ops Director to:

i.  repair light missing a cover

ii. Fill and seal hole in wall of kitchen corridor

iii. Clean and paint transition strip in door way from kitchen to back parking lot.

Extension will be requested until 5/17/2023 to complete the following work to correct the remaining violations:

i. The cracks in the floor will be sanded down, filled with stronger material, and sealed correctly per package instructions and oversight of Plant Ops Director.

ii. Doors will be removed, sanded down, and repainted with chip resistant paint, sealed with stronger primer, new kick plates installed on bottom half of doors, and porcelian door protector will be installed from door know to top of door to prevent further chipping and keep door a cleanable surface.

iii. FRP panels ordered to line wall leading into kitchen area to prevent further denting from meal tray carts.

2.) The system will be corrected to avoid further violation by using products designed for the wear and tear we place on building and equipment.

3.) Maintenance will be scheduled monthly in TELS to complete walk through to identify problem areas.

4.) ED of AL, Plant Ops Director, and SR ED

2. Resident 3 was admitted to the facility in 03/2012 with diagnoses which included paraplegia and type II diabetes.

During the entrance conference on 10/31/22, staff reported the resident required hands-on assistance in most ADLs.

Clinical record review during the survey revealed s/he was independent in grooming, evacuation status and use of the call light system.

Interviews with staff and Resident 3's evaluation, dated 10/25/22, revealed the current evaluation was not reflective of the resident's current status in the following areas:

* Use of side rails;

* Use of a transfer pole; and

* The resident's ability to evacuate.

The need to ensure the evaluation was reflective of Resident 3's current care needs was discussed with Staff 1 (ED) on 11/02/22. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required elements and failed to ensure quarterly evaluations were reflective of current care needs for 2 of 6  sampled residents (#s 3 and 4) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 10/2022 with diagnoses including chronic pain and venous insufficiency. The move-in evaluation lacked information on the following required areas:

* Customary routines related to eating and bathing;

* Interests and hobbies, social and leisure activities;

* Effective non-drug interventions for mood or mental health issues;

* Personality; and

* Pain, including how a person expresses pain or discomfort.

The need to ensure move-in evaluations included information on all required components was discussed with Staff 1 (ED) on 11/01/22. She acknowledged the findings.

1.) Immediate action taken was evaluation on resident #4 updated to reflect missing information on customary routines related to eating and bathing; interests and hobbies; social and leisure activities; effective non-drug interventions for mood or mental health issues; personality; and pain including how resident expresses pain or discomfort. Resident #3 was in the process of moving out related to need for higher level of care and has discharged from the facility.

2.) The system will be corrected by updating and implementing 'Generation's Oregon Evaluation Addendeum' which addresses effective non-drug interventions for mood or mental health issues, personality, and pain including how a person expresses pain or discomfort. In-service to review 'Generation's Oregon Evaluation Addendum' will be held with the health services team to implement form to be used with all residents for initial and ongoing evaluations per Oregon requirements.

An audit will be conducted to ensure all current residents have been evaluated for the items listed in the OAR's. Resident service plans will be updated to reflect any new or missing information.

Process update will include implementing 'Ongoing Evaluation Check List' to be used during all evaluations. This list includes all required and ancillary evaluations and will be used by RCC, HSD, and RN when a service plan is completed and turned in to ED for final review.

3.) The tracking system for compliance will be for the HSD to review and verify all 'Generation's Oregon Evaluation Addendums' and 'Ongoing Evaluation Check Lists' weekly. The ED and health services team will meet weekly to review completed evaluations.

4.) HSD,ED

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of resident's current care needs and provided clear direction to staff for 1 of 6 sampled residents (# 1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2020 with diagnoses including cardiovascular disease.

Review of the most recent service plan, dated 10/06/22, and interviews with staff during the survey, revealed the service plan was not reflective and lacked clear instruction in the following areas:

* Left-sided weakness, including instructions for dressing, transferring and repositioning; and

* History of verbal disagreements and aggression between the resident and another resident and behavioral interventions.

The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED) and Staff 4 (LPN/Health Services Director) on 11/02/22. They acknowledged the findings.

1.) Immediate action taken was service plan for resident #1 was updated to reflect clear directions for staff on how to care for resident needs such as dressing, transferring, and repositioning with left-sided weakness. Service plan for resident #1 was updated to reflect behavorial interventions to address history of verbal disagreements and aggression between resident and spouse who is also a resident at the facility.

2.) The system will be corrected by In-Service held with care staff regarding change of condition observations and reporting residents who have service plans that do not reflect accurately the care that needs provided. The 'Generation's Oregon Evaluation Addendum' and "Ongoing Evaluation Check List' will be implemented when completing all resident evaluations and service plans for new move in, 30 day post admission, quarterly, and change of condition. In-Service held for all health services team members who create or update service plans including RCC, HSD, and RN to review "Generation's Oregon Evaluation Addendum' and "Ongoing Evaluation Check List' as well as OAR requirements related to service plans being reflective of resident needs and clear directions to staff.  

An audit will be conducted to ensure all current resident service plans are reflective of their current care level and provide clear directions for staff related to care that needs provided.

3.) The tracking system for compliance will be for the 'Ongoing Evaluation Check List' to be used by RCC, HSD, and RN everytime a service plan is completed and will be turned in to ED for final review.

4.) HSD, ED

2. Resident 6 was admitted to the facility in 12/2020 with diagnoses including abrasion to the lower back and pelvis.

The current service plan, dated 09/04/22, noted the resident was incontinent of bowel and bladder and was at risk for skin breakdown.  Interventions included: monitor the resident's skin for redness, rash and irritation; provide perineal care several times a day; inspect the resident's skin on shower day; and medication aides administer treatment daily.

A progress note dated 09/18/22 noted a "...reopened 1.2 cm open sore on the right buttock..." and additional notes on 09/19/22 noted there were "...shallow open areas on the buttocks..."

Between 09/19/22 and the time of the survey, 10/31/22, there was no additional documentation related to the condition of the resident's skin.

During an interview on 10/31/22 at 1:50 pm, the surveyor requested Staff 3 (RN) to evaluate the resident's skin.  Staff 3 and the RN surveyor observed Resident 6's skin.  Staff 3 noted there were no open areas on the resident's buttocks.

Resident 6 had a change of condition related to skin, and there was no documented evidence the skin had been monitored weekly through resolution.

Short-term changes of condition with weekly monitoring through resolution was discussed with Staff 1 (ED) and Staff 5 (RCC) on 11/01/22. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were monitored, and progress documented at least weekly through resolution, and failed to determine interventions or actions and communicate the interventions or actions to staff for 3 of 5 sampled residents (#s 1, 3 and 6) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 03/2012 with diagnoses which included paraplegia and type II diabetes.

Clinical records, including progress notes from 08/02/22 to 10/23/22 and Resident  Interim Service Plans (ISPs) were reviewed.

The clinical record documented the following short-term changes of condition:

* 08/02/22 - Returned from hospital;

* 08/02/22 - Fall in the bathroom;

* 08/26/22 - Fall;

* 10/02/22 - Rash;

* 10/09/22 - Use of antibiotic to treat infection; and

* 10/11/22 - Returned from emergency department and had a new catheter.

There was no documented evidence the resident's short-term changes of condition, including skin status, falls and use of antibiotic, were monitored at least weekly to resolution.

On 11/02/22, the above findings were reviewed with Staff 1 (ED). Staff  acknowledged findings.

3. Resident 1 was admitted to the facility in 2020 with diagnoses including restless leg syndrome and depression.

Review of the resident's ISPs (Interim Service Plans) and 08/01/22 through 10/31/22 progress notes revealed the resident experienced the following short-term changes of condition:

* 08/12/22 - Fall;

* 08/14/22 - Two falls; and

* 10/30/22 - Resident-to-resident verbal altercation and aggressive behaviors.

There was no documented evidence the facility determined interventions or actions for Resident 1's short-term changes of condition, communicated the interventions or actions to staff on all shifts or monitored the conditions with progress noted at least weekly through resolution.

Short-term changes of condition and monitoring was discussed with Staff 1 (ED) and Staff 4 (LPN/Health Services Director) on 11/02/22. They acknowledged the findings.  

1.) Immediate action taken was LN completed skin check on resident #3 to ensure previous area of infection had cleared with no open areas or redness. Resident #3 was in the process of moving to higher level of care at time of survey and has discharged from the facility, no other immediate action was completed on resident #3.

Skin check was completed on resident #6 by facility RN and member of state survey team to ensure area was closed and resident #6 has been added to RN's weekly skin check list.

Service plan for resident #1 was updated to reflect interventions related to falls, verbal altercations, and aggressive behaviors with spouse. Hospice reviewed and changed medication orders, resident placed on alert for continued monitoring to review effectiveness. Care conference scheduled with resident and family to discuss options for 2 bedroom apartment, rearranging current 1 bedroom apartment to give each spouse their own quiet area and use of toileting space, or move 1 spouse to a studio apartment directly across the hall to accommodate their individual needs. Service plan updated for both residents with interventions for spousal disputes to keep them safe and supported.

2.) The system will be corrected by In-Service with all staff on short term change of condition monitoring and policy for alert charting on residents. Residents requiring alert charting will be tracked on Point Click Care Clinical Dashboard. The dashboard will be reviewed daily by care team. LPN, HSD, or RN will review the 24 hour report summary at the start of their shift to ensure all required alert charting completed each shift until LPN, HSD, or RN have reviewed and resolved the need for continued monitoring.

3.) The tracking system for compliance will be for residents on alert charting and the 24 hour report summary to be reviewed daily by LPN, HSD, or RN. The health services team will discuss residents with short and significant change of conditions at weekly health services team meeting with ED.

4.) LPN, HSD, RN, ED

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (# 3) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 03/2012 with diagnoses which included chronic pain.

Resident 3 had an order for Oxycodone 5 mg every six hours as needed for pain.

a. Resident 3's Controlled Substance Disposition Logs and MARs, reviewed from 10/01/22 - 10/31/22, revealed one occasion, 10/14/22, when staff signed on the drug disposition log the medication was given. However, the MAR lacked documentation the resident received the medication.

b. Staff documented on Resident 3's MAR they administered Oxycodone 5 mg on 10/15/22. However, the drug disposition log lacked documentation the medication was dispensed.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) on 11/02/22. Staff reviewed the documentation and acknowledged the discrepancies.

1.) Immediate action taken was for MT that had narcotic discrepency on resident #3 10/14/2022 to make late documentation to reflect the medication had been given along with follow up on outcome in resident electronic record.

2.) The system will be corrected by In-Service with MT's to review the process for signing out and documenting narcotic administration and documentation in MAR and narcotic book. Narcotic book audit will be completed monthly to include comparison of documentation in both locations.

3.) The tracking system for compliance will be for MT's to be held responsible to immediately document medications/treatments in MAR/TAR. HSD will perform monthly narcotic book audit.

4.) MT's, HSD

2. Resident 3 was admitted to the facility in 03/2012 with diagnoses which included heart failure.

Review of Resident 3's clinical records revealed the following:

Resident 3 was prescribed to check daily weight and notify the prescriber when the weight increased by two pounds or more in 24 hours.

Resident 3's 10/01/22 through 10/31/22 MAR indicated the resident had gained two or more pounds in 24 hours on five occasions: on 10/10/22, 10/13/22, 10/20/22, 10/25/22 and 10/27/22.

There was no documented evidence the prescriber had been notified when the resident's weight increased two or more pounds in 24 hours as prescribed.

On 11/26/22, the physician's orders and MARs were reviewed with Staff 1 (ED). Staff acknowledged the findings. No additional documentation was provided prior to exit.

Based on record review and interview, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include but are not limited to:

1. Resident 1 was admitted to the facility in 2020. The 10/01/22 through 10/31/22 MAR and 07/13/22 physician's orders were reviewed and revealed the resident had an order for Bisacodyl suppository (for constipation) PRN when s/he had not had a bowel movement within three days.

According to MAR, the resident did not have a bowel movement between 10/12/22 and 10/16/22.

There was no documented evidence a suppository was administered when the resident did not have a bowel movement within 3 days.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 4 (LPN/Health Services Director). They acknowledged the findings. No further information was provided.

1.) Immediate action taken was for resident #1 to be evaluated by LPN for constipation which was denied by resident. Interview with MT revealed that resident had been offered suppository per order but no documentation was made on attempt or refusal. MAR order updated to include the requirement for MT's to not only document if resident had bowel movement, but also what intervention was offered to resident based on order, and if intervention was accepted or declined by resident with proper documentation related to outcome. No immediate action was taken for resident #3 who was in the process of moving to higher level of care and has discharged from facility.

2.) The system will be corrected with In-Service for MT's to review policy and proceedure on following physician orders and resident refusal of medications.

Verbiage added to quarterly order request sent to all resident physicians to include space to indicate parameters for which they would like to be notified of refusals for their residents.

Intervention added to MAR for orders with parameters requiring physician notification to include MT's to document YES/NO on MAR/TAR if physician was notified.

Additional intervention created and implemented for residents on hospice to have bowel monitoring plan to include evaluation by LPN on day 3 of no bowel movement for constipation if resident refuses physician ordered intervention.

3.) The tracking system for compliance will be for a MAR/TAR audit to be completed weekly by lead MT's to review that physician orders are being followed. The audit will include pulling report from Point Click Care of resident medication refusals to ensure physicians were notified per their documented preference. Once completed, MAR/TAR audit will be reviewed by HSD.

4.) Lead MT's, HSD

2. Resident 3 was admitted to the facility in 03/2012 with diagnoses which included chronic pain.

Review of the resident's 10/01/22 through 10/31/22 MAR and physician's orders revealed the following:

a. Resident 3 was prescribed three medications to treat pain:

* Acetaminophen 325 mg every four hours as needed for pain;

* Oxycodone 5 mg every six hours as needed for pain; and

* Ibuprofen 600 mg every six hours as needed for pain.

The PRN pain medications lacked clear parameters for when to administer and which one should be given first.

b. Resident 3 was prescribed the following medications:

* MI-acid suspension 10 ml - 20 ml every four hours as needed for indigestion;

* Naphazoline-Pheniramine solution 1 - 2 drops every six hours as needed for allergies; and

* Ventolin 90 mcg inhaler 1- 4 puffs every four hours as needed for wheezing.

The multiple doses of the medication, eye drops and inhaler lacked clear parameters for when to administer between multiple doses.

c. Resident 3 was prescribed the following medications:

* Nystatin powder once daily and twice daily as needed for rash.

The multiple frequency of the treatment lacked clear parameters for when to administer daily versus two times daily.

The need to ensure the MAR was accurate and included medication-specific instruction and parameters for PRN medications was discussed with Staff 1 (ED) on 11/02/22. She reviewed the documentation and acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate medication administration record (MAR) was kept of all medications, including over-the-counter medications, which were ordered by a legally recognized prescriber and were administered by the facility for 3 of 6 sampled residents (#s 1, 2 and 3), whose records were reviewed.  Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2016 with diagnoses including atrial fibrillation and hypertension.

Review of Resident 2's MAR, dated 10/1/22 to 10/31/22, identified the following deficiencies:

* The MAR listed the following PRN bowel medications "for constipation": Milk of Magnesia, bisacodyl suppository, polyethylene glycol, Senna and sodium phosphate enema. No parameters were provided to direct the sequential order of use of these medications.

On 11/01/22 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Clinical Services).  They acknowledged the findings.

3. Resident 1 was admitted to the facility in 2020 with diagnoses including cardiovascular disease. The resident's 10/01/22  through 10/31/22 MAR was reviewed and revealed the following:

* PRN bowel medications to treat constipation, Milk of Magnesia and polyethylene glycol, lacked parameters on when to initiate treatment and what medication to administer first.

The need to ensure PRN medications included resident-specific parameters was discussed with Staff 1 (ED) and Staff 4 (LPN/Health Services Director) on 11/02/22. They acknowledged the findings.

1.) Immediate action taken was for resident #1 and resident #2 to have PRN orders reviewed and updated to include clear parameters and instructions for when MT's are to use. No immediate action was taken for resident #3 due to being in the process of moving to higher level of care and has discharged from facility.

2.) The system will be corrected by a MAR/TAR audit by MT's and ED to review all current orders related to citations around duplicate orders, clear parameters, and accuracy of orders compared to last physician signed quarterly review. Orders updated to ensure clear instructions on all PRN medications. In-Service for all staff on reviewing Triple Check Process when confirming or updating orders. PRN orders without clear instructions will be reviewed by facility RN to ensure accuracy and establish clear instructions on when to administer. Plan has already been implemented by facility for the health services team to take over faxing physicians for quarterly order reviews when completing quarterly service plan for consistancy and additional accuracy check effective in December 2022.

3.) The tracking system for compliance will be for all orders to be reviewed with Triple Check Process at time order is entered, confirmed, or updated in the MAR/TAR. Weekly MAR/TAR audit will include review of PRN medications. Quarterly orders will be reviewed prior to sending to physician to ensure clear instructions/parameters are in place or requested.

4.) MT's, HSD, RN, ED  

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 2 sampled residents (# 3) who self-administered insulin injections. Findings include, but are not limited to:

Resident 3's 10/01/22 - 10/31/22 MAR indicated the resident self-administered insulin injections two times daily.

During an interview on 11/02/22 at 9:30 am, Staff  20 (MA) confirmed the resident self-administered insulin injections.

A review of Resident 3's clinical records revealed the following:

There was no documented evidence the facility evaluated Resident 3's ability to safely self-administer the insulin injections.

During an interview on 11/02/22 at 9:58 am, Staff 3 (RN) confirmed that he had not completed an evaluation of the resident's ability to safely self-administer the insulin injections.

The need to complete evaluations of a resident's ability to self-administer medications initially and at least quarterly was discussed with Staff 1 (ED) on 11/02/22. Staff acknowledged the findings.

1.) No immediate action taken for resident #3 related to self-administration evaluation for insulin due to resident #3 was in the process of moving to higher level of care and has discharged from facility. An audit was completed on all current residents that self-administer medications/treatments to ensure a self-medication evaluation is in place.

2.) The system will be corrected by having the 'Ongoing Evaluation Check List' used by health services team for every service plan completed which includes list of all ancillary evaluations that are specific to each resident. Self-administration evaluation of insulin will be completed by delegating RN per required evaluation schedule or as needed with changes by physician.

3.) The tracking system for compliance will be having the 'Ongoing Evaluation Check List' completed by RCC, HSD, or RN when service plan is completed and turned in to ED for final review. Health service team will review list of recently completed service plans and "Ongoing Evaluation Check Lists' at weekly meeting with ED.

4.) RCC, HSD, RN, ED

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 evaluated prior to use, the resident was informed of the risks and benefits of the device, and instruction to caregivers on the correct use and precautions of the device was included on the service plan for 2 of 2 sampled residents (#s 3 and 6) who had side rails on their beds. Findings include, but are not limited to:

1.  Resident 6 was admitted to the facility in 12/2020 with diagnoses including abrasion to the lower back and pelvis.

During an interview and observation on 10/31/22, Resident 6's hospital bed was observed to have two half-length side rails in the up position.

There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT, including documentation of less restrictive alternatives evaluated prior to use, the resident had been informed of the risks and benefits of the device or the service plan had identified the correct use and precautions related to the device.

The lack of a side rail assessment was discussed with Staff 1 (ED) and Staff 5 (RCC) on 11/01/22 at 10:20 am. Staff acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2012 with diagnoses including paraplegia.

Observations of the resident and the resident's room on 11/01/22 showed bilateral half-length side rails were installed at the head of the hospital bed and were in the up position. The side rails appeared intact and in good repair.

Review of Resident 3's record revealed there was no documented evidence an assessment of the side rails had been completed.

In an interview on 11/02/22 at 8:50 am, Staff 1 (ED) confirmed no recent quarterly assessment had been completed for Resident 3's side rail use.

The resident's 07/23/22 service plan did not include any information related to the use of side rails, nor any instructions to staff about the correct use of and precautions for the device.  

The lack of a quarterly assessment and a service plan with clear instructions for side rail use was discussed with Staff 1 (ED) on 11/02/22. Staff acknowledged the findings.

1.) No immediate action taken for resident #3 as resident was in the process of moving to higher level of care and has discharged from facility.

Immediate action taken for resident #6 included RN completing safety device evaluation and updated service plan to include information related to side rails with clear instructions for staff regarding use and precautions related to the use of the side rails.

2.) The system will be corrected by implementing/delegating safety device evaluation to facility RN at time order for device is received to establish baseline. RCC's will complete safety device evaluation per quarterly service plan schedule and report any concerns or changes to RN for further evaluation. Audit will be completed to ensure all current residents have the required information in their service plan and any resident found to be lacking this information will have safety device evaluation completed in Point Click Care with service plan update.

Process update will include implementing 'Ongoing Evaluation Check List' with safety device evaluation listed as requirement for all levels of review including initial, new move in, 30 day post admission, quarterly, and change of condition. 'Ongoing Evaluation Check List' will be completed by RCC, HSD, or RN and turned in to ED for final review when complete.

3.) The tracking system for compliance is the 'Ongoing Evaluation Check List' to be completed by RCC, HSD, or RN when service plan update is complete and turned in to ED for final review. The health services team will review all recently completed service plans at weekly meeting with ED.

4.) RCC, HSD, RN, ED

3. Resident 13 was admitted to the facility in 06/2021 with diagnoses including lumbago with sciatica.

Observation made on 03/02/23 at 11:36 am, showed a quarter length side rail attached to the right side of the resident's bed. The resident was observed using the device to transfer on and off of the bed.

Resident 13's most recent service plan dated 12/15/22, lacked documented evidence caregivers were instructed on the correct use and safety precautions related to use of the device.

The need to ensure caregivers were instructed on the correct use and safety precautions related to use of Resident 13's side rail was discussed with Staff 1 (ED) and Staff 2 (RN) on 03/03/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had an thorough assessment completed by an RN, PT or OT prior to use, documentation of less restrictive alternatives evaluated prior to use, and instruction to caregivers on the correct use and precautions of the device included on the service plan for 3 of 3 sampled residents (#s 8, 10, and 13) who had side rails on their beds. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 11/2020 with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

During an observation on 03/03/23 at 10:25 am, Resident 10's hospital bed was observed to have two quarter-length side rails in the up position.

The resident's quarterly evaluation, dated 01/08/23, was reviewed. There was no documentation that other less restrictive alternatives were evaluated prior to the use of the device.

Resident's 10 service plan, dated 01/12/23, was reviewed. There was no information relating to the use of the side rail.

The need to ensure other less restrictive alternatives were evaluated prior to the use of a supportive device with restraining qualities and instruction to caregivers on the correct use of the device was included on the service plan was discussed with Staff 1 (ED) on 03/03/23 at 12:10 pm. She acknowledged the findings.

2. Resident 8 was admitted to the facility in 08/2016 with diagnoses including presence of left artificial hip joint and wedge compression fracture of T11-T12 vertebra.

During an interview with Resident 8 on 03/02/23 at 11:45 am, bilateral quarter-length side rails were observed on his/her hospital bed. The side rails were in the up position and fastened securely to the bed.

A review of the resident's record revealed no dcoumented evidence of the following:

* Whether the resident specifically requested or approved of the device;

* The facility informed the individual of the risks and benefits associated with the device;

* Other less restrictive alternatives were evaluated prior to the use of the device; and

* The facility instructed caregivers on the correct use and precautions related to the use of the device. The use of the side rails was not documented in the resident's current service plan.

The need to ensure all devices with restraining qualities had documentation of whether the resident specifically requested or approved of the device, the facility informed the individual of the risks and benefits associated with the device, other less restrictive alternatives were evaluated prior to the use of the device and instruction to caregivers on the correct use and precautions of the device was included on the service plan was discussed with Staff 1 (ED) and Staff 3 on 03/03/23. They acknowledged the findings.

1.) Immediate action taken was to properly update all service plans for residents #8, #10, and #13.

2.) The system will be corrected by holding inservice with all direct care staff on looking for and reporting medical assistive devices located in resident room and importance of safety checks on regular basis/also added to resident TAR for weekly safety check.

Building wide audit completed to get accurate list of residents with assistive devices and all residents identified had the following actions taken to correct or verify accurate information:

i. Consent form filled out and provided to resident/responsible parties to provide written consent of risks, preferences, and benefits of medical assistive device.

ii. Fax sent to PCP requesting update order for medical assistive device and once order obtained, information updated in PCC to print as order for quarterly order verification/renewal then scanned into resident chart.

iii. Verification of RN initial assement or coordination to get completed and signed off in PCC. Evaluation date set to ensure it populates quarterly for RCC/HSD ongoing use.

iv. TELS system updated to ensure maintenance monthly safety checks are on schedule. Medical device check and implementation process extended on "Ongoing evaluation check list" established during POC for initial survey as well as new admission process to include MD order, Consent on file, RN assessment complete, and information added to TELS system. PCC dates reset to ensure they populate on a quarterly schedule to correlate with quarterly service plan.

3.) Tracking system for compliance will be updated for ED to run weekly medical assistive device report in PCC and compare with medical assistive device list saved in the shared drive so all office staff can access and update as needed to catch any discrepancies. This information will be discussed at weekly health services meeting.

4.) RCC, HSD, ED

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) to generate the facility's staffing plan and meet the regulation for 1 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6), whose records were reviewed. Findings include, but are not limited to:

In an interview on Wednesday, 11/01/22, Staff 1 (ED) confirmed the facility's staffing plan for day shift Wednesdays, which consisted of 80 caregiving hours or 10 direct care staff. Review of the ABST revealed 123.62 caregiving hours or 15 direct care staff were needed for day shift on Wednesdays.

There was no documented evidence the facility used the ABST to generate a staffing plan which was reflective and met the 24-hour scheduled and unscheduled needs of residents.

There was no documented evidence the facility completed an ABST for Resident 4  prior to move-in, or updated the ABST at least quarterly for Residents 1, 2, 3 and 6, or when Resident 5 experienced a significant change of condition.

The requirements of the ABST were discussed with Staff 1 on 11/02/22. She acknowledged the findings.

1.) Immediate action taken was for ABST tool to be updated by moving discharged residents to archive section and adding missing residents to tool for compliance. An email was sent to contact provided by survey team to inquire about time frames and concerns of multi-reporting on time for tasks

2.) The system will be corrected by adding and implementing ABST tool to the 'Ongoing Evaluation Check List' to ensure it is updated accurately each time service plan is updated. In-Service with RCC, HSD, and RN to review expectation and requirements for ABST tool use.

Audit will be completed to ensure all current resident service plans are reflected appropriately in ABST tool per regulations. Staff responsible for completing new move in, 30 day post admission, quarterly, or change of condition service plans will use 'Ongoing Evaluation Check List' and turn in to ED for final review.

ED will pull ABST tool hours for staffing coordinator to use when creating and posting upcoming monthly schedule to ensure acuity hours are accurately reflected in the facility staffing plan. ABST tool will be reviewed at weekly health services team meeting with ED to ensure required changes have been made related to resident acuity and that information is passed on to staffing coordinator to adjust staffing plan hours as needed.

3.) The tracking system for compliance is for the 'Ongoing Evaluation Check List' to be completed at each service plan review and will include ABST tool update as ancillary update to complete. Once 'Ongoing Evaluation Check List' is completed, it will be turned in to ED for final review. Health services team will review resident acuity changes weekly with ED at health services team meeting and staffing coordinator will review staffing plan hours based on resident acuity with ED at weekly staffing meeting.

4.) Staffing coordinator, RCC, HSD, RN, ED

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 10) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 11/02/22 at 8:45 am revealed the following:

There was no documented evidence Staff 9 (MA), hired 02/24/22, and Staff 10 (CG), hired 01/20/22, had demonstrated competency in all required areas and within 30 days of hire including:

* Changes associated with normal aging;

* Conditions that require assessment, treatment, observation and reporting; and

* General food safety, serving and sanitation.

The need to document demonstrated competency of job duties was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Clinical Services) on 11/02/22. Staff acknowledged the findings.

1.) Immediate action taken was providing staff #9 and #10 with accurate list of missing classes/trainings including changes associated with normal aging; conditions that require assessment, treatment, observation, and reporting; and general food safety, serving, and sanitation. Training with demonstrated compentency in these areas was completed.

Audit was conducted to confirm completion status of all Royal Anne new hires to ensure any missing pre-service and within 30 day compentency trainings have been completed.

2.) The system will be corrected by revising the 'New Hire Check List' to include sections for pre-service training and within 30 days trainings. Staffing coordinator will review relias training for completion of all required pre-service items prior to scheduling new hires to train on the floor with residents. Staffing coordinator will schedule all new hires for dedicated time to complete relias training throughout their first 30 days of employment. When all relias and compentency trainings with demonstration have been completed, staffing coordinator will turn 'New Hire Check List' in to ED for final review.

3.) The tracking system for compliance will be to ensure all new hire staff traning requirements are met and will be evaluated on a daily and as needed basis depending on new hire onboarding levels and turnover. Training requirement will be reviewed on date of new hire to establish clear expectations and timeframes. Staffing coordinator will review 'New Hire Check List' with new hires on a weekly basis until complete. ED and staffing coordinator will review current list of trainings at weekly staffing meeting. SrED and ED will discuss problematic staff or training struggles at weekly 1:1 for accountability.

4.) Staffing coordinator, ED, SrED

Based on interview and record review, it was determined the facility failed to ensure and document 1 of 2 long-term staff (# 19) completed 12 hours of annual in-service training, including at least 6 hours related to dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 11/02/22 and revealed the following:

There was no documented evidence Staff 19 (MT), hired 09/13/21, completed at least 12 hours of training related to the provision of care in CBC, with a minimum of six hours of training on dementia care topics, between 09/13/21 and 09/13/22.

The need to ensure long-term staff completed the required number of hours of annual in-service training was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Clinical Services) on 11/02/22. She acknowledged the findings.

1.) Immediate action taken was providing staff #19 with accurate list of missing classes/trainings to meet the 12 hour requirement need including at least 6 hours related to dementia care topics.

Audit was conducted to confirm completion status of all annual training requirements for Royal Anne staff. Staffing coordinator will schedule time for staff to complete any missing trainings.

2.) The system will be corrected by revising the 'New Hire Check List' to include sections with clear instructions for new hire, within 30 days, and annual trainings. Staffing coordinator will schedule all care staff in 1 hour increments each month to complete ongoing annual trainings. SrED will schedule and track all annual training requirement and compliance for non care staff.

3.) The tracking system for compliance will be for the staffing coordinator to review report for scheduled trainings weekly with ED at staffing meeting for all care staff. SrED will review compliance report for scheduled trainings for all non care staff.

4.) Staffing coordinator, ED, SrED

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month and to provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records and an interview with Staff 7 (Maintenance) on 11/01/22 identified the following deficiencies:

There was no documented evidence fire drills were conducted every other month or fire and life safety instruction was provided to staff on alternating months.

On 11/01/22 the need to conduct fire drills every other month and provide fire and life safety instruction to staff on alternating months, in accordance with the OFC, was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Clinical Services). They acknowledged the findings.

1.) Immediate action taken was fire drill conducted and accurately documented. Consistant location for storing completed documentation was established by ED and communicated with Director of Plant Operations and SrED.

2.) The system will be corrected by adding fire drills and life safety trainings as a monthly task in TELS (maintenance software) with requirement for Director of Plant Operations to sign off monthly.

Copies of completed drills and In-Service documentation will be provided to ED and SrED by Director of Plant Operations within 24 hours of scheduled trainings unless otherwise communicated.

A list of life safety drills will be established to accommodate realistic need for drill while maintaining compliance requirements. Trainings/Drills will be coordinated in advanced and placed on the schedule to review during all staff meetings or other scheduled times to include but not limited to elopement, fire extinguisher use, and active shooter.

3.) The tracking system for compliance is the Director of Plant Operations will be responsible to follow scheduled drills and trainers per ED direction and provide proper documentation of complettion on a monthly basis. The ED is responsible to check in with Director of Plant Operations on a monthly basis for accountability. Any concerns or failure to provide required trainings will be communicated with SrED.

4.) Director of Plant Operations, ED, SrED

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 11/01/22 and an interview with Staff 7 (Maintenance Technician) identified the following deficiencies:

There was no documented evidence training on fire safety was provided to residents at least annually.

On 11/01/22 the need to provide and document fire safety instruction to residents at least annually, in accordance with the OFC, was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Clinical Services). They acknowledged the findings.

1.) Immediate action taken was coordination with leader of the Resident Communication Forum group to add time for ED to review topic at next meeting.

The 'New Resident Orientation Check List' was updated to be in compliance with OAR Fire and Life safety requirements for resident trainings within 24 hours of admission. 'New Resident Orientation Check List' will be given to HSD for review after completed by care staff.

2.) The system will be corrected by implementing a triggered assessment in Point Click Care to populate for health services team members to review with residents during service plan meeting per annual schedule. Triggered assessment will be added to 'Ongoing Evaluation Check List' as ancillary evaluation to complete annually.

Director of Plant Operations, ED, and SrED will coordinate and schedule 1 building wide annual drill to include but not limited to topics of earthquakes and active shooter.

3.) The tracking system for compliance will be for the health services team to review the Point Click Care triggered assessment for annual resident fire and life safety training per schedule and turn 'Ongoing Evaluation Check List' in to ED for final review upon completion. All 'Ongoing Evaluation Check Lists' will be reviewed weekly with ED at health services team meeting.

4.) HSD, ED, Director of Plant Operations, SrED

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 240 and C 340.

Refer to citation C240 and C340