The findings of the re-licensure survey, conducted 10/27/2021 through 10/29/2021, 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 re-visit to the re-licensure survey of 10/29/21, conducted 01/19/22 through 01/20/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

3. Resident 2 was admitted to the facility in 11/2020 with diagnoses including hypertension, asthma, and anxiety.

The evaluation available to the staff and survey team during the survey was last reviewed and updated on 5/22/21.

On 10/29/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5), whose records were reviewed. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in 02/2018.

The evaluation available to the staff and survey team during the survey was last reviewed and updated on 04/01/21.

On 10/29/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

2. Resident 4 was admitted to the facility in 05/2021.

The evaluation available to the staff and survey team during the survey was last reviewed and updated on 06/01/21.

On 10/29/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

4. Resident 3 was admitted to the facility in 04/2019.

The evaluation available to the staff and survey team during the survey was last reviewed and updated on 04/03/21.

On 10/29/21 the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

5.  Resident 5 was admitted to the facility in May 2018.

The evaluation available to the staff and survey team during the survey was last reviewed and updated on 4/1/21.

On 10/29/21, the need to ensure that the facility performed evaluations at least quarterly, to correspond with the quarterly service plan updates was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Residents 1-5: Plans/interventions for all sample reviewed and for effectiveness and accuracy. All remaining service plans reviewed to verify accuracy and will be reviewed on the correct schedule.

2. Re-education provided to the ALD, RN, and staff to assure clarity on service plans and change of condition. Daily oversight will be provided by ED at stand up. All service plans will be brought to stand up

3. Daily

4. Executive Director, ALD, and RN

2. Resident 2 was admitted to the facility in 11/2020 with diagnoses including alcoholism and Korsakoff syndrome from alcohol use.

The resident's service plan, dated 05/22/21, was reviewed and caregiving staff were interviewed. The service plan was reviewed with Staff on 10/28/21, and staff were interviewed from 10/27/21 to 10/29/21.

The service plan documented that Resident 3 did not require staff support with alcohol use, however, interviews and progress notes revealed incidents on 10/7/21, 10/8/21, and 10/11/21 when staff held medications due to alcohol consumption and completed alert charting due to alcohol intoxication.

The need to ensure service plans were reflective of the resident's current condition, provided clear instruction and the service plan was updated quarterly was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services) on 10/29/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff and were followed for 3 of 5 sampled residents (#s 2, 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 04/2019 with diagnoses including Parkinson's disease, anxiety and chronic pain.

Resident 3's service plan, dated 04/03/21 was not reflective or lacked clear direction to staff in the following areas:

*Ability to ambulate without assistance;

*Need for eating assistance; and

*Pain issues, indicators of pain and non-drug interventions.

On 10/29/21 the need to ensure service plans were reflective of current needs, provided clear direction to staff and were followed was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Resident service plans have been updated to reflect their most current health and preference needs.

2. By 12/28/21 all residents will have a complete review of their service plans to ensure their accuracy and that they are reflective of the current needs and preferences of all residents

3. In-service will be held by 12/28 for all staff to understand the service plan rule and their role in it.

4. Service plan binder will be brought to stand up each day and reviewed by the entire team for any changes from the previous day (The team)

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

Resident 2,3,4 and 5's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 10/29/21, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Resident service plans have been updated to reflect their most current health and preference needs.

2. By 12/28/21 all residents will have a complete review of their service plans to ensure their accuracy and that they are reflective of the current needs and preferences of all residents.

2b. Residents and families will receive and invitation to each appt to participate in the service plan if they desire (in person or remotely)

3. In-service will be held by 12/28 for all staff to understand the service plan rule and their role in it.

4. Service plan binder will be brought to stand up each day and reviewed by the entire team for any changes from the previous day and which designee will contact family (The team)

3. Resident 2 was admitted to the facility in 11/2020 with diagnoses including hypertension, asthma and anxiety.

Physician orders and MARs for Resident 2, reviewed from 10/1/21 - 10/27/21, revealed the following orders were not followed:

* Hydrocodone Acetaminophen 10-325 mg for pain was not administered on 17 occasions;

* Hydrochlorothiazide 25 mg for hypertension was not administered on four occasions;

* Diclofenac sodium 1% gel for pain was not administered on two occasions; and

* Magnesium oxide 400 mg supplement was not administered on four occasions.

Reasons listed on the MAR for not administering the medications included "BP cuff not working", "could not find in med room", and "medication not arrived".

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services) on 10/29/21. They acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 4 of 4 sampled residents (#s 2, 3, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 05/2021 with diagnoses including hypertension and dementia.

Physician orders and MARs for Resident 4, reviewed from 10/1/21 - 10/27/21, revealed the following orders were not followed:

* Amlodipine 5 mg (for hypertension) was not administered as ordered on six occasions;

* Clonidine HCL 0.1 mg (for hypertension) was not administered as ordered on six occasions;

* Eliquis 5 mg (blood thinner) was not administered as ordered on four occasions;

* Amox-Clav 875-125 mg (antibiotic) was not administered as ordered on six occasions; and

* Memantine HCL 10 mg (for cognition) was not administered as ordered on two occasions.

Reasons listed on the MAR for not administering the medications included "device not working" and "medication not arrived".

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Executive Director) and 2 (Director of Health Services) on 10/29/21. They acknowledged the findings. No further information was provided.

2. Resident 3 was admitted to the facility in 04/2019 with diagnoses including Parkinson's disease. Review of the resident's MAR, dated 10/01/21 to 10/27/21, and physician orders, dated 09/03/21 identified the following deficiencies:

The physician orders included an order for staff to perform daily temperature monitoring for COVID 19 precautions.

The MAR listed four instances (10/01/21, 10/02/21, 10/05/21 and 10/14/21) where COVID 19 temperature monitoring was not performed as ordered.

Reasons listed on the MAR for not administering the treatment as ordered included "device not working" and "no thermometer".

On 10/29/21 the need to ensure all written, signed orders from a legally recognized practitioner were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

4. Resident 5 was admitted to the facility in 4/2018.

Physician orders and MARs for Resident 5, reviewed from 10/1/21 - 10/27/21, identified the following orders were not followed as prescribed:

* Haloperidol 2mg/ml (for nausea/vomiting/hallucinations/delusions) was not administered as ordered on three occasions; and

* Omeprazole 20mg (for GERD) was not administered as ordered on two occasions.

Reasons listed on the MAR for not administering the medications included "cannot locate syringe" and "medication not arrived".

On 10/29/21, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Medication availability has been verified for all residents.

All medications orders have been reviewed with the charts to ensure they are scheduled per the most current MD orders.

2. Weekly med tech meetings will be held by ED or designee to ensure quality training and understanding of the job for all med techs.

3.

Based on interview and record review, it was determined the facility failed to ensure MARs were complete and accurate for 3 of 4 sampled residents (#s 2, 3 and 5). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2020 with diagnoses including hypertension, asthma and anxiety.

The resident's 10/1/21 through 10/27/21 MARs, TARs and physician orders dated 9/3/2021 were reviewed. The MARs/TARs contained multiple blank spots in the documentation for the following scheduled daily treatments and medications:

* Hydrochlorothiazide 25 mg for hypertension;

* Montelukast 10 mg for opening airways / breathing;

* Diclofenac sodium 1% gel for pain;

* Hydrocodone Acetaminophen 10-325 mg for pain;

* Melatonin 3 mg for sleep aid;

* Acetaminophen 325 mg for pain;

* Magnesium oxide 400 mg supplement;

* Multivitamin tablet for supplement; and

* Vitamin B-1 100 mg for supplement.

The need for accurate records was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services) on 10/29/21. The staff acknowledged the findings.

2. Resident 5 was admitted to the facility in 05/2018.

The resident's 10/1/2021 through 10/27/21 MARs and TARs and physician orders were reviewed. The MARs/TARs contained multiple blank spots in the documentation for the following routine treatments and medications:

* Ensure liquid for promoting weight gain;

* Haloperidol 2mg/ml for nausea/vomiting/hallucinations/delusions;

* Lorazepam 0.5mg for anxiety/restlessness;

* Morphine 30 mg for pain;

* Omeprazole 20mg for Gerd; and

* Senna 8.6 mg for constipation;

On 10/29/21, the need for accurate records related to administration of medication was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. All residents orders reviewed to verify presence of reason for use or corresponsing diagnosis.

2. MAR review will be completed by the Administrator or Designee weekly to ensure all new medications have a reason for use or corresponding diagnosis.

5. The Regional Nurse Consultant will review new medications order weekly to ensure all medications have reason for use or corresponding diagnosis.

Based on interview and record review, it was determined the facility failed to evaluate a resident, at least quarterly for the ability to safely self-administer his/her own medications, and to perform such an evaluation for each resident who resided in the unit for 1 of 1 sampled resident (#3) whose records were reviewed.  Findings include, but are not limited to:

Review of Resident 3's self-administration of medication evaluation, dated 3/15/21 and interviews with staff identified the following deficiencies:

*The evaluation was not completed quarterly as required;

*The evaluation did not address the medications had been administered by the resident's spouse, rather than by Resident 3; and

*In an interview on 10/28/21, Staff 1 (Executive Director) stated that Resident 3's spouse was administering his/her medications, and acknowledged that no such evaluation had been completed for the resident's spouse.  

On 10/29/21 the need to evaluate residents, at least quarterly for the ability to safely self-administer medications, and the need to complete an evaluation for each person who resided in the unit was discussed with Staff 1 and Staff 2 (Director of Health Services).  They acknowledged the findings.

1. Resident 3 and their spouse have had a completed Self med evaluation by the community RN. The resident's physician has been communicated to and signed off on the spouse providing medication oversight.

2. Staff will be inserviced on self medication and the proper policy and OAR from start to finish including the RN and ALD.

3. Weekly

4. The Ed will review weekly at the ALD one on one

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 7 and 10) completed all required pre-service training prior to beginning their job responsibilities. Findings include, but are not limited to:

Training records were reviewed on 10/28/21. Records indicated the required pre-service orientation topics and pre-service dementia training were not documented as completed prior to staff working with residents for Staff 5 (MT) hired 9/24/21, Staff 7 (CG) hired 9/25/21, and Staff 10 (CG) hired 10/31/21.

On 10/29/21, the need for staff to complete the required pre-service orientation and dementia training before working with residents was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Pre service dementia training is now completed for all required staff.

2. Community leadership has been re-educated on the training requirements, regulations and community protocol to assure understanding.

3. Ongoing compliance will be monitored through employee training file audits upon completion of the general orientation process and monthly thereafter.

4. All new health services employees will have their dementia training records scanned and sent to Regional Nurse Consultant.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 3 and 8) were trained in the use Abdominal Thrust and First Aid. Findings include, but are not limited to:

Staff 3 (CG) hired on 8/5/21, and Staff 8 (CG) hired on 4/22/21, failed to have documented evidence of competency demonstrated of First aid and Abdominal Thrust completed within 30 days of hire date.

On 10/29/21, the need to ensure staff had documented evidence of competency demonstration in assigned duties, within 30 days of their hire date, was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services). They acknowledged the findings.

1. Missing training for  the sampled staff is now complete.

2. By 12/1 an audit of all remaining staff conducted to verify presence of required First Aid, Abdominal Thrust and CPR will be completed.

3. by 12/15 all required staff will have the required training outlined above.

4. Master copies of their certifications will be kept in a separate binder and will be reviewed monthly by Administrator and Safety Committee.  

Based on interview and record review, it was determined the facility failed to meet requirements for fire and life safety drills and instruction, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 10/28/21 identified the following deficiencies:

*There was no documented evidence that fire and life safety instruction was provided to staff on alternating months; and

*There was no documented evidence that fire drills were conducted on alternating months.

On 10/29/21 the need to ensure all requirements were met for fire and life safety drills and instruction, in accordance with the OFC was discussed with Staff 1 (Executive Director) and Staff 2 (Director of Health Services).  They acknowledged the findings.

1. Schedule has been created for monthly fire drills and will be completed without exception.

2. Administrator will forward to Director of Operatons monthly for review.

3. By 12/28 Director of Operations will ensure training has been provided to Administrator on proper documentation for fire drills.

Based on interview and record review, it was determined the facility failed to meet requirements for fire and life safety instruction and documentation, in accordance with the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Review of facility records on 10/28/21 identified the following deficiencies:

There was no documented evidence that annual training on fire safety was provided to residents.

On 10/29/21 the need to ensure all requirements were met for fire and life safety instruction and documentation, in accordance with the OFC was discussed with Staff 1 (Executive Director) and staff 2 (Director of Health Services).  They acknowledged the findings.

1. Schedule has been created for monthly fire drills and will be completed without exception.

2. Administrator will forward to Director of Operatons monthly for review.

3. By 12/28 Director of Operations will ensure training has been provided to Administrator on proper documentation for fire drills

4. By 12/28 all residents will have attended a resident safety orientation and this will be part of our monthly Resident Town Hall to discuss fire and life safety topics.