Print Inspection: 0UUS

The findings of the re-licensure survey, conducted 05/08/23 through 05/10/23, 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

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 on 5/10/23, conducted on 10/17/23, 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.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner for 1 of 1 sampled resident (#3) who experienced a significant change of condition related to a pressure wound. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 08/2021 with diagnoses including diabetes.

On 03/01/23, progress notes indicated the resident had an open wound on the left buttocks. A 03/01/23 temporary service plan indicated wound was related to pressure. A health status note by Staff 2 (RN) on 03/04/23 stated "will assess next Thursday." An RN assessment for a Stage 2 pressure wound was completed by Staff 2 on 03/10/23.

Staff 2 was unavailable for interview during the survey.

The facility failed to ensure an RN assessment was completed in a timely manner.

The need for a timely RN assessment to be completed for a significant change of condition was discussed with Staff 1 (ED) and Staff 17 (Regional Wellness Director) on 05/10/23. They acknowledged the findings.

1.What action was taken to correct the rule for each example/resident?

a.Resident #3 had an updated RN assessment addressing resident's change of condition on 3/10/23.

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

a.Regional RN reviewed with community RN and Wellness Director the core components and timeliness of a significant change of condition assessment.

b.The community will utilize the electronic health record/MAR for tracking changes of condition for more consistent monitoring and notification.

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

a.Weekly Clinical meetings will be used to monitor for compliance.

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

a.The RN will ensure RN assessments are completed timely with required elements.

b.The ED will review the system and ensure documentation is completed.

Compliance Date for implementation of corrective action and review of systems to ensure compliance is 7/9/23.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#6) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 05/08/23, Resident 6 was identified to be administered insulin injections by non-licensed staff.

Resident 6's MARs, reviewed from 04/01/23 - 05/08/23, revealed insulin had been given by Staff 6 (RCC), 12, 13 and 15 (MTs) on several occasions.

Review of delegation documentation on 05/10/23 revealed the following:

a. The re-evaluation of delegation for Staff 6, dated 11/09/22, and for Staff 8, dated 11/15/22, lacked documentation in the following areas:

* Nursing assessment of the condition of the resident; and

* Subsequent re-evaluations including rationale.

b. The initial delegations for Staff 13, completed on 02/23/23, and Staff 15, completed on 04/07/23, lacked documentation in the following areas:

* Nursing assessment of the client;  

* Rationale that task can be safely delegated to caregiver;

* Skills, abilities and willingness of caregiver;

* Caregiver taught task is client specific and not transferable;

* Frequency the resident should be reassessed by the RN, including rationale for the frequency based on the resident's needs;

* Frequency and rationale for how often the unlicensed person(s) should be supervised and re-evaluated based on the competency of the caregiver; and

* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN is supervising performance.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) and Staff 17 (Regional Wellness Director) on 05/10/23 at 10:15 am. They acknowledged the findings and no further information was provided.

1.What action was taken to correct he rule for each example?

oResident #6 had their delegation paperwork completed including RN assessment and rationale on 6/30/2023 date.

oThe skills, ability and willingness of caregiver was reevaluated for Staff 13 on 6/30/2023 as well as documentation completed for delegation by the RN.

oThe skills, ability and willingness of caregiver was reevaluated for Staff 15 on 6/30/2023 date as well as documentation completed for delegation by the RN.

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

oThe RN will review and update all nurse delegation paperwork for other residents and staff to ensure documentation meets standards by June 30, 2023.

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

oThe system will be reviewed at least weekly through plan of correction period and on an ongoing basis to ensure compliance.

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

oExecutive Director will audit the staff Delegation documents binder and ensure all areas of the required documentation are completed and report to Regional RN for additional support if needed.

Based on interview and record review, it was determined the facility failed to ensure there was an effective system in place for tracking controlled substances for 1 of 2 sampled residents (# 5) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 10/2022 with diagnoses including hypertension and depression.

The resident's 04/01/23 through 05/08/23 MARs, current physician orders, and Controlled Substance Disposition log entries were reviewed. The following was identified:

* The resident had a physician order for hydrocodone/APAP (a pain reliever) 5/325 mg one tablet by mouth twice daily as needed.

* Three entries were documented in the Controlled Substance Disposition log, but not on the resident's MAR:

- 04/25/23 at 4:38 pm;

- 05/05/23 at 9:21 pm; and

- 05/07/23 at 4:31 pm.

* Both page 17 and page 36 of the Controlled Substance Disposition log had an entry on 04/29/23 at 4:35 pm for one tablet of hydrocodone/APAP. One administration of the medication for this date and time was documented on the resident's MAR.

The need to ensure MARs and Controlled Substance Disposition logs matched was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings and indicated she would investigate the discrepancies.

1.What action was taken to correct the rule for each example?

oResident #5's narcotic log will be audited and compared to MAR to determine discrepancies on June 30th, 2023, by Wellness Director.

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

oStaff in-serviced on 5/24/2023 regarding following the Narcotic policies and procedures.

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

oNarc book will be audited and compared to the MAR bi-weekly to ensure compliance.

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

oExecutive Director and Wellness Director will audit the Narcotic logbook to ensure all areas of the required documentation are completed by June 30th, 2023.

2. Resident 2 was admitted to the facility in 05/2023 with diagnoses including weakness related to cerebral infarction.

The resident's 05/01/23 through 05/08/23 MAR and physician orders were reviewed, and the following was identified:

* Five supplements did not have a reason for use documented; and

* An order for PRN glycopyrrol 1 mg tab (for secretions) did not have resident-specific parameters related to dosage.

The need to ensure all medications on the MAR indicated reasons for use and all PRN medications had resident-specific parameters was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included documented reasons for use and/or provided clear instruction and parameters for administration of PRN medications for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2023 with diagnoses including hypertension and atrial fibrillation.

The resident's 04/01/23 through 05/08/23 MARs and physician orders were reviewed and the following was identified:

* There was no reason for use documented on the MARs for any of Resident 1's medications.

The need to ensure all medications on the MAR included the reason for use was discussed with Staff 1 (ED), Staff 3 (Wellness Director/LPN) and Staff 17 (Regional Wellness Director) on 05/10/23. They acknowledged the findings.

4. Resident 3 was admitted to facility in 08/2021 with diagnoses including diabetes.

The resident's 05/01/23 through 05/08/23 MAR and physician orders were reviewed, and the following was identified:

* Betamethasone 0.05% ointment lacked a reason for use.

The need to ensure all medications on the MAR indicated reasons for use was discussed with Staff 1 (ED) and Staff 17 (Regional Wellness Director) on 05/10/23. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 06/2022.

Review of Resident 4's 04/01/23 through 05/08/23 MAR, identified the following deficiencies:

* Senna 17.2 mg, once daily, failed to identify reason for use.

On 05/10/23, the need to ensure all medications on the MAR indicated reasons for use was discussed with Staff 1 (ED). She acknowledged the findings.

1.What action was taken to correct the rule for each example?

oResident #1, Resident #2, and Resident #3 had their 90-day physician orders faxed to Primary Care Physicians to review and provide reasons for use on 6/30/2023.

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

oExecutive Director will meet with Wellness Director, Community RN, and Resident Care Coordinator weekly on Thursdays at 3pm. Will monitor for compliance of ensuring all diagnosis/reason for use are entered on the MAR and will also be looking for resident specific PRN parameters related to the medication and dosage.

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

oMonthly review of the MAR will be performed by Executive Director and Wellness Director on every 3rd Wednesday of the month, and RN will be notified of all medications without diagnosis requiring an RN, as well as any orders without parameters requiring RN. We have discussed that a MedTech is able to enter the diagnosis/reason for use on orders that the prescriber has provided the information for.

4.Who will be responsible for the corrections are completed/monitored?

oExecutive Director, Wellness Director, and Registered Nurse will perform audit of MAR weekly.

Based on interview and record review, it was determined the facility failed to ensure an RN, PT, or OT had completed a thorough assessment prior to the use of supportive devices with restraining qualities for 1 of 1 sampled resident (#5) who used side rails. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 05/2023 with diagnoses including weakness related to cerebral infarction.

The resident's initial service plan was reviewed and identified s/he had side rails on his/her hospital bed. A copy of the side rail assessment was requested and received on 05/08/23. The assessment form was completed on 05/01/23 and was signed by Staff 3 (Wellness Director/LPN).

The need for an RN, PT, or OT to complete an assessment prior to the use of supportive devices with restraining qualities was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

1.What action was taken to correct the rule for each example?

oExecutive Director provided in-service to outside vendors to provide teaching on supported devices and the importance of following protocol and steps here in assisted living including notifying community Wellness Director and RN of assistive device needing assessed.

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

oWellness Director completed audit of each assisted living residents' room to ensure all assistive devices in use are in compliance.

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

oSchedule monthly safety and compliance checks with Plant Operations and housekeepers to ensure community is aware of all devices in use.  

4.Who will be responsible for the corrections are completed/monitored?

oExecutive Director will audit safety and compliance checks to ensure all areas of the required documentation are reported to RN June 30th, 2023.

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 ABST must address all the required ADLs for each resident and the amount of staff time needed to provide care.

The facility tool did not include updated information and minutes for multiple residents.

On 05/10/23, the need to use an ABST which addressed all the ADLs for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED). She acknowledged the findings.

1.What action was taken to correct the rule for each example?

oExecutive Director and Wellness Director have met reviewed/audited the ABST. Added all residents receiving medication administration as well as made updates to reflect residents' care on 6/30/2023.

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

oExecutive Director and Wellness Director will meet with staff as needed to discuss resident care plans to ensure accuracy of ABST.

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

oWeekly clinical meetings will be used to monitor for compliance on 6/30/2023.

4.Who will be responsible for the corrections are completed/monitored?

oExecutive Director and Wellness Director to meet with staff as needed to ensure compliance of ABST.

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

Fire and life safety records dated 10/27/22 through 03/15/23 were reviewed on 05/08/23. The following was identified:

a. There was no documented evidence staff were provided fire and life safety instruction on alternating months.

b. Fire drills were not consistently conducted every other month, written fire drill documentation did not include all the required elements, and there was no documented evidence alternate exit routes were used during drills.

The need to provide fire and life safety instruction to staff on alternate months, to consistently conduct fire drills every other month, to document all required elements for fire drills, and to document the use of alternate exit routes as required by the OFC was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

1.What action was taken to correct he rule for each example?

oFire drill performed on 5/19/2023.

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

oCommunity new Plant Operations director will perform a fire drill every other month to ensure compliance.

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

oBi-monthly Plant Operations Director will perform state required drills.

4.Who will be responsible for the corrections are completed/monitored?

oPlant Operations Director and Executive Director will ensure all required drills are performed to maintain compliance on 6/30/2023.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admit and at least annually as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 05/08/23.

There was no documented evidence residents were provided fire and life safety procedure training within 24 hours of admission to the facility or were being 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 instructed in fire and life safety procedures within 24 hours of admission and at least annually thereafter per the OFC was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

1.What action was taken to correct the rule for each example?

oExecutive Director scheduled and completed a town hall meeting with residents on 5/26/2023 to discuss Resident Fire Life & Safety Training

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

oExecutive Director will notify Plant Operations Director of all new residents moving in and ensure either he or Executive Director is available to review and sign the "Resident Fire & Life Safety Training" at move in.

3.Who will be responsible for the corrections are completed/monitored?

oExecutive Director and Plant Operations Director will provide Resident Fire & Safety Training for residents on 6/30/2023.