The findings of the change of ownership survey, conducted 06/13/23 through 06/14/23 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

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

Resident 1 was admitted to the facility in 07/2021 with diagnoses which included bi-polar, Alzheimer's disease, anxiety and nicotine dependence.  

An interview with care staff, observations of the resident during the survey, and the service plan, dated 03/27/23, revealed it was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Behavior interventions;

* Activities of interest;

* Sleeping routine relating to a heat pack;

* Where evening snacks were located; and

* Frequency of smoking.

The need to ensure the service plan was reflective of Resident 1's current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (RCC) during an interview on 06/14/23 at 11:25 am. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Resident 1 discharged on 6/22/23.  

2.How will the system be corrected so this violation will not happen again?

Education provided to designated administrator about services plans on 7/22/23. When patients admit, direct care staff will be educated on service plans prior to working their first shift.

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

When patients admit, service plans will be reviewed at least quarterly during IDT meeting and if there is a change of condition.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated to determine what action or intervention was needed for the resident, communicated the action or intervention to staff on each shift, and weekly progress documented until the condition resolved for 1 of 1 sampled resident (#1) who experienced changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2021 with diagnoses including Alzheimer's disease.  

The resident's medical chart was reviewed. Resident 1 experienced the following short term changes of condition:

* 03/16/23 - Mouth pain;

* 04/14/23 - Blood observed on lower lip; and

* 05/04/23 - Vomiting.

Although progress notes identified the changes of condition and provided some information, there was no documented evidence of an evaluation which would determine what action or intervention was needed for the resident, that the actions or interventions were communicated to staff on each shift, or weekly progress was documented until the condition resolved.

The need to ensure short-term changes of condition were evaluated to determine what action or intervention was needed for the resident, the actions or interventions were communicated to staff on each shift, and weekly progress was documented until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 06/14/23 at 11:25 am. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Resident 1 discharged on 6/22/23.

2.How will the system be corrected so this violation will not happen again?

Education provided to designated administrator about change of condition and monitoring on 7/22/23. When patients admit, direct care stafff will be educated on change of condition and monitoring prior to working their first shift.

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

When patients admit, temporary service plan will be reviewed weekly during staff meeting.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.   

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the residents' facility records for all medications and treatments that the facility was responsible to administer for 1 of 1 sampled resident (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2021 with diagnoses including pain and COPD (Chronic Obstructive Pulmonary Disease).

The resident's 05/01/23 through 06/13/23 MARs and physician's orders dated 05/25/23 were reviewed. The following was identified:

* On 05/04/23, the physician's office documented an order to administer 650 mgs of acetaminophen (for fever and pain) at 11:22 pm. There was no documentation the medication was administered per the physician's order.

* On 05/05/23 the facility administered ondansetron (for nausea). There was no documented evidence of a signed order for the medication.

* On 05/10/23 there was no documentation if scheduled medications were administered which included acetaminophen, melatonin (for sleep), divalproex (for bipolar disorder) and Wixela inhaler (for COPD) at 8:00 pm.

The need to ensure medication orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the residents' facility records for all medications and treatments that the facility was responsible to administer was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 (RCC) on 06/14/23 at 11:25 am. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Resident 1 discharged on 6/22/23.

2.How will the system be corrected so this violation will not happen again?

Education provided to designated administrator about treatment orders on 7/22/23. When patients admit, medication technicians will be educated on treatment orders prior to working their first shift.

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

When patients admit, new orders will be reviewed on the next business day during staff huddle.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 1 sampled resident (#1) whose MARs were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2021 with diagnoses including lower back pain.

The resident's 05/01/23 through 06/13/23 MARs were reviewed and revealed the following:

* Lack of resident-specific instructions for two PRN pain medications, including sequence of administration; and

* Inconsistent documentation relating to staff applying lotion to the resident's feet during the day and evening shift.

During an interview on 06/13/23 at 2:23 pm, Staff 3 (RCC) identified the resident being independent in applying lotion to his/her feet twice a day.

The need to ensure there were clear parameters for staff when administering multiple PRN medications for the same condition and staff were accurately documenting on the MAR was discussed with Staff 1 (Administrator), Staff 2 (RN) and Staff 3 on 06/14/23 at 11:25 am. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Resident 1 discharged on 6/22/23.

2.How will the system be corrected so this violation will not happen again?

Education provided to designated administrator about medication administration on 7/22/23. When patients admit, medication technicians will be educated on medication administration prior to working their first shift.

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

When patients admit, new orders will be reviewed on the next business day during staff huddle.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 5 and 7 ) completed all required pre-service training orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed on 06/14/23 and identified the following:

a. Staff 5 (MT), hired on 10/11/22, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents:

* Resident rights and values of CBC care;

* Abuse reporting requirements;  

* Fire safety and emergency procedures; and

* Written job description.

b. Staff 7 (Dietary), hired on 04/25/23, lacked the documented evidence pre-service orientation training was completed in the following areas:

* Resident rights and values of CBC care;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Food handler's certificate.

The need to ensure all required pre-service training's were completed prior to beginning their job responsibilities was reviewed with Staff 1 (Administrator) on 06/14/23. She acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Staff 5 is no longer employed by the RCF.

Staff 7 is no longer employed by the RCF, however, provided the food handlers certificate that was completed on 4/24/23.

2.How will the system be corrected so this violation will not happen again?

Education provided to designated administrator about caregiver requirements on 7/22/23. When patients admit, staff will receive pre service orientation that meets all requirements of the rule prior to working their first shift.

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

No residents currently reside in the facility, and no admissions are planned. There are no staff employed by the RCF.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired direct care staff (#5) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records on 06/14/23 identified Staff 5 (MT), hired 10/11/22, lacked documented evidence competency was demonstrated in the following required areas:

Topics without documented evidence of training within 30 days of hire:

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

Topics trained on after the 30 days of hire:

* Role of service plans in providing individualized care; and

* Changes associated with normal aging.

The need to ensure staff demonstrated competency in required training within 30 days of hire was discussed with Staff 1 (Administrator) 06/14/23. She acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Staff 5 is no longer employed by the RCF.

2.How will the system be corrected so this violation will not happen again?

No residents currently reside in the facility, and no admissions are planned. There are no staff employed by the RCF.

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

No residents currently reside in the facility, and no admissions are planned. There are no staff employed by the RCF.

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records dated 11/30/22 through 05/16/23, were reviewed on 06/13/23. The following deficiencies were identified:

* Lack of documented evidence fire drills were conducted every other month.

* Fire drill documentation did not include the following required elements:

   -Location of simulated fire origin; and

   -Problems encountered with comments relating to residents who resisted or failed to participate in the drills.

* Lack of documented evidence fire and life safety instruction was provided to staff on alternate months.

The need to follow OFC requirements pertaining to fire drills, documentation, and staff training was discussed with Staff 1 (Administrator), Staff 4 (Maintenance Director), and Staff 9 (Intermediate Care Facility Administrator) on 06/14/23. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Fire drill was completed on 7/13/23 & 7/21/23.

2.How will the system be corrected so this violation will not happen again?

The Maintenance Director and designated administrator was re-educated on the regulations and procedures relating to fire drills and training. Fire drills and training will be conducted every other month per regulation utilizing ICF Staff.

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

Monthly audits will be conducted to ensure compliance.  

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the Residential Care Facility's (RCF) common-use areas were maintained in good repair, chemicals and toxic materials were maintained in a locked storage unit, and grounds were kept orderly and free of litter and refuse. Findings include, but are not limited to:

Observations of the outside of building and the interior courtyard on 06/13/23 revealed the following:

* Multiple drop-offs along the pathways, up to three inches;

* Unlocked storage of chemicals and toxic materials in the interior courtyard; and

* Refuse in the interior courtyard grounds which included discarded gardening pots and tools, boards with rusty nails, and wire fencing.

The facility was toured with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 06/13/23. They acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Resident 1 discharged on 6/22/23.  No residents currently reside in the facility, and no admissions are planned. A lock was installed. Lawn and garden bed areas will be levelled up with topsoil. Refuse was cleaned up.

2.How will the system be corrected so this violation will not happen again?

The building Maintenance Director was re-educated regarding general building exterior safety.  

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

Safety rounds will be conducted weekly x 4 weeks, then monthly x 2 months to ensure compliance. Results will be reviewed at the Safety Committee for further recommendations.

3.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on observation and interview, it was determined the facility failed to ensure the design of the Residential Care Facility (RCF) supported the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 06/13/23.  There were no handrails observed on one or both sides in the corridor located to the left of the main entrance, leading to the RCF's common area.  

The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (Administrator) on 06/14/23. She acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Handrails by main entrance leading to the RCF common area were installed.

2.How will the system be corrected so this violation will not happen again?

Handrails will be installed in the identified corridor area.

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

Safety rounds to ensure handrails are appropriate will be conducted weekly x 4 weeks, then monthly x 2 months to ensure compliance. Results will be reviewed at the Safety Committee for further recommendations.  

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.

Based on observation and interview, it was determined the facility failed to ensure an exit door alarm or other acceptable system was provided for security purposes and to alert staff when residents exited the Residential Care Facility (RCF). Findings include, but are not limited to:

The facility was toured on 06/13/23. It was observed the front door, and two exit doors used by residents to access outdoor courtyards did not have an operating system that would alert staff when a resident exited the building.

On 06/14/23 the need to ensure the facility provided an exit door alarm or other acceptable system to alert staff when residents exited the RCF was discussed with Staff 1 (Administrator). She acknowledged the findings.

1.What actions will be taken to correct the rule violation for each example/resident?

Door chimes were installed at the courtyard doors to alert staff to residents leaving the building.

2.How will the system be corrected so this violation will not happen again?

Resident exit doors will have door chimes to alert staff to residents leaving the building.

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

Safety rounds to ensure doors chimes are functioning will be conducted weekly x 4 weeks, then monthly x 2 months to ensure compliance. Results will be reviewed at the Safety Committee for further recommendations  

4.Who will be responsible to see that the corrections are completed/monitored?

Administrator/designee is responsible.