Print Inspection: 0DDV

The findings of the change of ownership survey, conducted 06/10/24 through 06/12/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 06/12/24, conducted 11/18/24 through 11/21/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

2. Resident 2 was admitted to the facility in 06/2022 with diagnoses including dementia.

Resident 2 was observed during the survey to utilize a wheelchair with footrests in place. Resident 2 required staff assistance and escort for mobility.

In interviews with caregiving staff on 06/10/24 and 06/11/24, they explained Resident 2 required escort in the wheelchair for mobility and the footrests were used at all times.

Resident 2's service plan, dated 04/24/24, indicated Resident 2 mobilized independently in the wheelchair and did not provide instruction to staff related to the use of footrests.

The need to ensure service plans were reflective of resident care needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 3 (RCC) on 06/11/24 and 06/12/24. 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 care needs and provided clear directions to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 04/2021 with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, pacemaker, and dementia.

Observations were made of the resident's care on 06/12/24 at 10:36 am. Interviews with facility staff and the resident were conducted. The current service plan dated 04/15/24 was reviewed.

Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Instructions for signs and symptoms of infection to report when providing care to the   suprapubic insertion site;

* Instructions on perineal and skin care;

* Skin condition monitoring;

* Pacemaker precautions, instructions for proper maintenance, and how to monitor malfunctions;

* Instructions on edema management;

* Nebulizer equipment, precautions, and instructions for proper maintenance;

* Changes of condition to report to home health;  

* Hearing;

* Transfers;

* Ambulation and use of assistive devices;

* Behavioral problems; and

* Non-pharmaceutical interventions for pain, including how the resident expressed pain or discomfort.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 06/11/24 and 06/12/24. They acknowledged the findings. No further information was provided.

Resident 1's care plan has been updated to reflect the resident's care needs and correct the deficency noted during the survey 07/11/24.

Resident 2's care plan has been updated to reflect the resident's care needs and correct the deficency noted during the survey 07/11/24.

Care plans will be reviewed by entire Care Planning Team during care conferences and changes of condition. Each Care Plan has been printed, and made available for staff to make notes and alert Resident Care Coordinator to changes needed for care plans as well which will be reviewed daily in clinical meeting.

In addition to meeting quarterly during care conferences, Care Planning Team will meet weekly to audit (3) charts to ensure care plans are accurate and reflective of resident care needs for 7 weeks.  

The Executive Director will be responsible for ensuring the corrections have been implemented, and monitoring for continued compliance.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed 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 04/2021 with diagnoses including chronic obstructive pulmonary disease, atrial fibrillation, pacemaker, and dementia.

Review of Resident 1's current physician orders, MARs from 05/01/24 through 06/10/24, and bowel documentation from 05/01/24 through 05/31/24 revealed the following:

* Hydrocodone/Acetaminophen (APAP) 5/325 mg was ordered to be administered one tablet four times daily as needed for pain. The MAR indicated five doses of Hydrocodone/APAP were administered 05/20/24 through 05/21/24 within one 24-hour period; and

* Milk of magnesia suspension 400 mg/5 ml was ordered to be administered 30 ml as needed for constipation with instruction to administer on day four if the resident did not have a bowel movement for three days. According to the bowel documentation, the resident did not have a bowel movement on four consecutive days from 05/01/24 through 05/04/24, and from 05/19/24 through 05/22/24. However, the MAR indicated milk of magnesia for bowel care was administered on 05/05/24 and 05/23/24, in each case the fifth day without a bowel movement.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 06/11/24 and 06/12/24. They acknowledged the findings. No further information was provided.

Resident 1: On 7/5/24 All medication administration care staff were in-serviced on six rights of medication administration, on physician's orders, and where to verify prior administration details in PCC before administering medications that have parameters on dosing in a 24hr period. All staff have been in-serviced on the bowel protocol, how to verify in PCC and when to implement.

Going forward, clinical alerts in PCC will flag residents on bowel protocol, which will be evaluated daily, Monday-Friday in clinical meeting to ensure compliance with bowel protocols being implemented/followed per physician's orders. PRN audits will be conducted during same clinical meeting to ensure physician orders are being followed and any issues corrected.

The Executive Director will be responsible for ensuring the corrections have been implemented and monitoring for continued compliance.  

Based on interview and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that met the regulation. Findings include, but are not limited to:

The facility staffing tool was reviewed with Staff 1 (ED) on 06/11/24.

Review of the facility ABST documentation identified there was no evidence ABST assessments were completed for each resident at least quarterly and with significant changes in condition.

The need to ensure ABST assessments were completed for all residents at least quarterly and with significant changes in condition was discussed with Staff 1 (ED) on 06/11/24. He acknowledged the findings.

The ABST tool has been reviewed by the Executive Director for each resident in the facility, and updated to correct deficency noted during survey by date of compliance.

Going forward, the ABST tool will be reviewed prior to move-in,30 days post move-in, at significant changes of condition, and at quaterly care conferences

The ABST tool will be monitored/evaluated monthly by the Executive Director to ensure the corrections have been implemented and maintained.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 06/11/24, fire drill and fire and life safety records for the previous six months were requested.

Review of the documentation provided revealed there was no documented evidence the facility conducted unannounced fire drills on alternate months.

The need to conduct unannounced fire drills on alternate months was discussed with Staff 1  (ED) and Staff 6 (Maintenance Director) on 06/12/24. They acknowledged the findings. No further information was provided.

Maintainence Director has been inserviced on Fire and Life Safety regulations pertaining to fire drills. Appropriate fire drill has been performed for the month of June, and in-service/education for July. Documentation has been updated to reflect deficencies noted during survey.

Going forward, a schedule highlighting months needed for unannounced fire drills has been established by Maintainence director, and proper documenation will be used.

Compliance with alternate month fire drills / education will be audited monthly at the Safety Committee meeting.

The Executive Director is responsible for ensuring these corrections have been completed and monitored

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed, at least annually, on fire and life safety procedures according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 06/11/24 at 11:50 am.

There was no documented evidence residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need for residents to be re-instructed about fire and life safety procedures at least annually per the OFC was discussed with Staff 1 (ED) and Staff 6 (Maintenance Director) on 06/12/24. They acknowledged the findings. No further information was provided.

Annual Fire and Life Safety training has been completed for all residents in the facility for 2024 07/05/24.

Going forward Fire and Life Safety resident training will be conducted annually and audited monthly during Safety Committee Meeting to ensure compliance of annual education as well as move-in training

Executive Director will be responsible for ensuring completion of corrections, and monitoring ongoing compliance.

During the survey, concerns were identified in the following areas and the facility was provided with technical assistance:

(d) Each individual has privacy in his or her own unit.

During the survey, concerns were identified in the following areas and the facility was provided with technical assistance:

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 361, C 420, and C 422.

Refer to C 361, C 420, and C 422 POC

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260 and C 303.

Refer to C 260 and C 303 POC