Print Inspection: 2OQP

The findings of the re-licensure survey conducted 01/04/22 through 01/06/22 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, 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

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 01/06/22, conducted 04/04/22 through 04/05/22, 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 57 for Memory Care Communities.

2. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia.

Progress notes indicated Resident 5 had an unwitnessed fall on 10/27/21 at 5:57 am, bruising found on 11/10/21 at 2:58 am and a second unwitnessed fall on 11/10/21 at 9:25 pm.

An incident report, dated 10/27/21, stated the resident was found on the floor while the night shift staff were doing their last rounds. The report included Resident 5's statement that s/he fell on his/her bottom. There was no additional information to show how the facility was able to rule out abuse or neglect.

A progress note, dated 11/10/21, stated the resident was on alert charting for the above mentioned fall on 10/27/21 and went on to report, "Resident has bruise on knee (R) which is dark purple." There was no follow up documentation indicating where the bruising came from and if it was related to the fall.

An incident report, dated 11/10/21, reflected, "Resident stated [s/he] was trying to stand up and use [his/her] phone but fell backwards onto [his/her] buttocks. [S/He] denied any pain from the fall. No visible injuries noted." There was no additional information to show how the facility was able to rule out abuse or neglect for the unwitnessed fall.

The need to ensure all incidents were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure unwitnessed falls and resident incidents were thoroughly investigated to rule out abuse/neglect and reported to the local SPD office, as appropriate, for 2 of 3 sampled residents (#s 1 and 5) with incidents. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia.

Progress notes indicated Resident 1 had an unwitnessed fall on 01/01/22. An incident report, dated 01/01/22, stated Resident 1 was found on the floor and "another resident was laying in resident's bed where [s/he] was previously laying before being found on the floor." The initial incident documentation revealed staff were unable to determine what happened and unable to rule out abuse or neglect. There was no documented evidence the facility immediately reported the incident to the local SPD office and investigated to determine ways to prevent the reoccurrence.

The need to ensure all incidents were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings and the above incident was reported to the local SPD office on 01/06/22, per surveyors request.

1 - Resident #1 Incident was reported to local APS office during time of survey and closed at intake. Resident #5 all incident reports reviewed and not negative outcomes to sited residents.

2 - All incident reports will be reviewed daily during stand-up/clincial team meetings to assure that all incidents are being investigated and reported timely. ED and RN/DHS will assure that incident reports are signed and meet requirements.

3 - All current staff will be in-serviced on abuse/neglect reporting and investigations. All new staff will be inserviced on Abuse/Neglect reporting as part of their onboarding process.

4 - ED, RCCs, RN/DHS will QA two incident reports/month as part of the ongoing QA process

Executive Director, Director of Health Services

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

On 01/04/22 at 11:30 am, the facility kitchen was observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Walls throughout the kitchen;

* Underneath the dish machine and three compartment sink; and

* Floor perimeter.

b. The following areas needed repair and/or cleaning:

* The walk-in freezer had a large accumulation of ice throughout, including on the fans;

* The area around the ceiling vents had missing paint, were peeling and/or had holes;

* The faucet of the three compartment sink was running and could not be turned off; and

* The fire sprinkler above the plate warmer was covered with dirt and cobwebs.

The areas that required cleaning and repair were observed and discussed with Staff 1 (Regional Director) on 01/06/22. The findings were acknowledged.

1 - Kitchen deep cleaning will take place including walls, floors, and all surfaces mentioned in 2567. Kitchen repairs as indicated are in process and will be fixed by compliance date.  

2 - Dietary manager and staff will use work order, kitchen cleaning audits and weekly walk throughs for on-going complaince.

3- Weekly as a part of ongoing compliance

ED, RDO, Dietary Manager, Maintenance Director Responsible

2. Resident 6 was identified as a smoker during the acuity interview on 01/04/22.

Interviews with Resident 6, Staff 1 (Regional Director) and Staff 3 (RCC) on 01/04/22 and 01/06/22 confirmed Resident 6 smoked independently.

Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since 03/03/20.

The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 on 01/06/22. She acknowledged the findings.

3. Resident 2 was admitted to the memory care unit December in 2021 with diagnoses including dementia. The following components were not addressed on the resident's move-in evaluation:

* Interests, hobbies, social and leisure activities;

* Confusion and decision making abilities;

* Personality including how the person copes with change or challenging situations;

* Assistance needed for personal hygiene;

* Assistive devices relating to mobility; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature.

The need to ensure all required components were addressed on the move-in evaluation was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure quarterly smoking evaluations were completed timely for 2 of 2 sampled residents (#s 6 and 7) and ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2)  whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 7 was identified as a smoker during the acuity interview on 01/04/22.

Interviews with Resident 7 on 01/04/22 confirmed s/he smoked multiple times a day, independently.

Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since 05/14/21.

The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 (Regional Director) and Staff 3 (RCC) on 01/06/22. They acknowledged the findings.

1 - Resident #6 and #7 Smoking evaluations have been completed. A complete audit of all community smokers will be conducted to assure that evaluations are completed. Resident #2 was re-assesed with updated evaluation tool completed.  

2 - RNC educated interdisciplanary team on move-in evaluations and evaluation process. All evaluations will be done in conjunction with the residents service plan ongoing

3 - ED will review all move-in evaluations for completeteness to assure all components as required. An audit of evaluations will be conducted as part of the monthly QA process for ongoing compliance

ED is reponsible

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 4 of 6 sampled residents (#s 1, 2, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in October 2015 with diagnoses including MS and was able to self-direct his/her own care.

Resident 6's service plan included "Has a port, that is taken care of by Providence Home Infusion."

There was no further information on the care and safety of the port or what concerns staff should watch for and report.

In interview on 01/06/22, Staff 1 (Regional Director) confirmed Resident 6 had a port in his/her upper right chest that was managed by an outside provider.

The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1 on 01/06/22. She acknowledged the findings.

3. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. Observations from 01/04/22 through 01/06/22 were made, interviews with staff were conducted and medical records were reviewed. The following components were either not reflective of the resident's current care needs or did not provide clear direction to caregiving staff:

* Daily routine;

* Bathing;

* Grooming and personal hygiene assistance;

* Oral hygiene including brushing natural teeth and caring for partial dentures;

* When to provide housekeeping and laundry services;

* Making choices within his/her own abilities and what those are;

* Behaviors, how the resident exhibits them and interventions;

* How often to check on the resident;

* Assistance needed with toileting;

* Transfer pole;

* Dining preferences and assistance needed;

* Mobility;

* Preference for the resident's door to be locked; and

* Preference to stay in bed.

4. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. Observations from 01/04/22 through 01/06/22 were made, interviews with staff and the resident's family were conducted and medical records were reviewed. The following components were either not reflective of the resident's current care needs or did not provide clear direction to caregiving staff:

* Behaviors, including how the resident exhibits them and interventions;

* Frequency of safety checks;

* Time the resident spends in his/her room;

* Sleeping routine and preferences;

* Dressing assistance;

* Toe guard placement;

* Grooming assistance including hand and face washing and oral care;

* Chair alarm;

* Bed alarm;

* Siderails relating to use, what to monitor them for and who to report to if they are loose or in need of repair;

* Mobility device used;

* Ambulation assistance;

* Ability to transfer out of bed independently with the perimeter mattress;

* Sleep interventions including exercise and napping;

* Daily routine;

* Fall interventions;

* Where the resident eats meals;

* Left hand splint;

* Frequency of checks relating to toileting assistance; and

* Interventions relating to nose bleeds.

The need to ensure residents' service plans were reflective of their current provision of care and provided clear caregiving instruction was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia.

The current service plan, dated 09/15/21, and temporary service plans were reviewed. The service plan was not reflective of the resident's current status in the areas of:

* Use of devices including a bed alarm, wheelchair and protective head gear;

* Current activities and ability to participate;

* Mobility;

* Fall risk and current interventions; and

* Locking of the apartment door.

During interviews on 01/04/22 and 01/06/22, direct care staff stated the resident needed a wheelchair for most mobility, used head protective gear and a bed alarm daily, and the door to the apartment was kept locked.

The need to ensure service plans were reflective of residents' current status was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident 1, 2, 5, 6 service plans will be updated and care conference held

2 - ED to conduct inservice with staff on the proper service planning process and to review OAR with the service planning team to assure that all areas of resident care and needs are met as part of the service planning process. Evaluation tool in PCC was changed to feed directly to the service plan

3 - As part of the monthly internal QA process community will audit 2 SPs for accuracy

RN, RCCs, ED are responsible

2. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. The resident's clinical records were reviewed and staff were interviewed.

A facility document entitled SL Resident Evaluation, dated 11/18/21, reflected the resident became "anxious when the spouse was not available, even just to go into the other room." It also reflected Resident 2's spouse lived in Seaside, Oregon which was a two hour trip to the facility.

In an interview on 01/05/22 at 10:05 am, Staff 10 (MC CG) confirmed the resident preferred to stay in his/her bed, screamed when taken out of his/her room and was not doing well with the transition. The resident had been evaluated by home health speech therapy on 12/21/21 and put on a pureed diet. Staff 10 reported Resident 2 only took one to two bites of meals and drank about one third of the nutritional supplement that was offered three times a day.

There was no documented evidence Resident 2 was monitored upon admission for signs or symptoms of anxiety or loss due to being away from his/her spouse. There was also no documented evidence staff communicated to management the resident's decreased intake after the speech evaluation was completed and the pureed diet was implemented.

3. Resident 5 was admitted to the memory care unit in April 2021 with a diagnosis of dementia. Progress notes, dated 09/20/21 through 01/03/22 were reviewed and revealed the following incidents had not been monitored through resolution:

*  09/20/21 - Increased confusion during the night;

* 11/02/21 - Covid booster administered;

* 11/08/21 - Urinary tract infection;

* 11/09/21 - Start of a new medication;

* 11/10/21 - Bruising to right knee;

* 11/10/21 - Non-injury fall; and

* 12/23/21 - Left index finger abnormality.

Resident 5 had a fall on 10/27/21 and on 11/10/21. Neither fall had documented evidence of new interventions implemented and monitored for effectiveness.

The need to determine and document what actions or interventions were needed when a resident experienced changes of condition, monitor the interventions for effectiveness and monitor changes of condition through resolution was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to identify changes of condition, determine and document what actions or interventions were needed for the resident, communicate these to staff and monitor the conditions to resolution for 3 of 6 sampled residents (#s 1, 2 and 5) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia.

a. Review of Resident 1's clinical record revealed the resident experienced multiple falls between 10/08/21 and 01/01/22. Several of the falls resulted in injuries to the resident. Incident reports and investigations were reviewed and lacked any new interventions identified to try and prevent additional falls. The facility had some interventions in place, however, there was no documented evidence the interventions were being monitored for effectiveness.

Direct care staff interviewed on 01/05/22 stated Resident 1 remained unsteady on his/her feet, required use of a wheelchair for mobility and a bed alarm that was used to alert staff when the resident moved in bed.

b. Resident 1's clinical record revealed the resident had multiple skin injuries which occurred between 10/2021 and 01/2022, including the following:

* 10/08/21: laceration with sutures to forehead;

* 11/24/21: toenail removed;

* 11/30/21: laceration to head; and

* 11/30/21: skin tear to elbow.

The record lacked documentation weekly of progress noted until the conditions resolved.  

On 01/06/22 the need to determine and document what actions or interventions were needed when a resident experienced changes of condition, monitor the interventions for effectiveness and monitor skin conditions to resolution was discussed with Staff 1 (Regional Director). She acknowledged the findings.

1 - Residents 1,2,5 Change of Condition were reviewed and documentation completed reflecting the changes and SP updated as needed.

2 - 24 hour process will be reviewed and retrained with staff to assure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED, RCCs, will review in clincical meeting daily and address/document accordingly. Training to be conducted with facility care staff

3 - Review of 24 hour binder and audit tool will be conducted Mon-Fri during clinical meetings

ED, RN, RCCs are responsible

Based on interview and record review, it was determined the facility failed to ensure physician orders were documented in the resident's facility record or were carried out as prescribed for 2 of 7 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in December 2021 with diagnoses including dementia. Current physician's orders and the 12/13/21 through 01/04/22 MARs were reviewed.

There was no documented evidence of a physician's order in the resident's facility record for scheduled acetaminophen (used to treat pain) and no clear orders relating to administering either 50 mgs or 100 mgs of Losartan (used to treat high blood pressure).

The need to ensure there were physician orders located in the resident's facility record for all medications the facility was responsible to administer and the facility was following physician orders for those medications was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

2. Resident 1 moved into the facility in June 2021 with diagnoses including dementia.

Signed physician orders on 10/05/21, and the 11/01/21 through 01/04/22 MARs were reviewed and revealed the following orders were not followed:

* Polyethylene Glycol (bowel medication): take 17 g by mouth daily, can use as needed for constipation; and

* Sennosides-Docusate Sodium 50 mg oral tab (bowel medication): take 1 tablet by mouth 2 times a day as needed for constipation.

In a discussion with Staff 1 (Regional Director), she indicated hospice would be contacted and the orders would be clarified and followed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 on 01/06/22. She acknowledged the findings.

1 - Comprehensive physican's order review was  conducted for residents #1, and #2, in addition all physican orders will be reviewed for accuracy by date of compliance  

2 - Inservice all facility Med Techs on order processing and review

3 - Audit Physician's orders alongside the MAR weekly for 6 weeks and the monthly after during 24 hour review process.

Bring any findings to internal QA meeting monthly

RCC's/RN/ED responsible  

Based on interview and record review, it was determined the facility failed to notify the physician or prescriber when a resident refused to consent to orders for 2 of 2 sampled residents (#s 2 and 5) who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 2's 12/13/21 through 01/04/22 and Resident 5's 12/01/21 through 01/04/22 MARs and corresponding progress notes were reviewed. The residents' record showed multiple medication and treatment refusals.

There was no documented evidence the facility notified the physician each time the residents refused to consent to the orders.  

The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Regional Director) and Staff 2 (RN). They acknowledged the findings.

1 - Resident #2 and #5 orders to be updated to reflect MD preference for notifcation when medication is refused.

2 - Inservice Med Techs and RCCs on proper notification of refused medications.

3 - RCC's to check for refused medications daily and assure proper notifications were made x4 weeks and then spot check 2 monthly as part of internal QA process. Bring findings to monthly internal QA meetings

RCC's/RN/ED responsible

5. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. The resident's 12/13/21 through 01/04/22 MARs and progress notes were reviewed and revealed the following:

* References to "hold/see nurse notes" on multiple entries with no documentation on why the medication was held or corresponding nurses notes; and

* Multiple blanks without documentation of if the medication was administered.

6. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. The resident's 12/01/21 through 01/04/22 MARs and progress notes were reviewed and revealed multiple blanks on the MARs without documentation if the medication and treatments were administered.

The need to ensure residents' MARs were accurate and included documentation of medications administered or why a medication was held was discussed with Staff 1 (Regional Director) and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

3. Resident 3 was admitted in December 2015 with diagnoses including hyperlipidemia and chronic pain.

The residents 12/2021 and 01/01/22 through 01/05/22 MARs and physician orders dated 09/23/21 were reviewed and revealed the following:

* Staff failed to initial on the MAR if the resident's blood pressure and pulse were obtained on 12/04/21 and 01/04/22; and

* PRN pain medications prescribed for the same condition lacked resident specific parameters and clear instruction for unlicensed staff regarding administration;

On 01/06/22 the need to ensure MARs were accurate and PRN medications contained clear instructions to unlicensed staff was discussed with Staff 1 (Regional Director). She acknowledged the findings.

4. Resident 1 was admitted in June 2021 with diagnoses including dementia.

The residents 11/01/2021 through 01/04/22 MARs and physician orders were reviewed and revealed the following:

The January 2022 MAR had a physician's order for Bisacodyl 10 mg suppository, as needed for constipation. The PRN bowel medication lacked resident specific parameters and clear instruction for unlicensed staff regarding when to administer the medication.

On 01/06/22 the need to ensure MARs were accurate and PRN medications included clear instruction for staff was discussed with Staff 1 (Regional Director). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs included reason for use, resident-specific parameters for PRN medications, staff signatures for administering medication, specific instruction to unlicensed staff on what time to administer medications or that reference notes had been followed up on for 6 of 7 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose MARs were reviewed. Findings include, but are not limited to:

1.  Resident 4's 12/01/21 through 01/04/22 MARs were reviewed and revealed the following inaccuracy:

The MAR instructions for the following medications - finasteride, clopidogrel bisulfate, protonix delayed release, trelegy ellipta aerosol powder and refresh lacri-lube ointment stated a range of times for administration of medications, but did not provide specific instruction to unlicensed staff on specific administration times.

In an interview with Staff 2 (RN) on 01/05/22 at 2:20 pm, she stated she was unsure why there were a range of times and not a specific time.

In an interview with Staff 3 (RCC) on 01/06/22 at 9:55 am, she stated the pharmacy sent the prescriptions with a range of administration times.  

The need to ensure unlicensed staff were given clear instruction on when to administer medication was discussed with Staff 1 (Regional Director) on 01/07/22. She acknowledged the findings.

2.  Resident 7's 12/01/21 through 01/04/22 MARs were reviewed and revealed the following inaccuracy:

The MAR instructions for the following medications - dapsone, finasteride, tamsulosin HCI and titropium bromide monohydrate stated a range of times for administration of medications but did not provide specific instruction to unlicensed staff on specific administration times.   

In an interview with Staff 2 (RN) on 01/05/22 at 2:20 pm, she stated she was unsure why there was a range of times and not a specific time.

In an interview with Staff 3 (RCC) on 01/06/22 at 9:55 am, she stated the pharmacy sent the prescriptions with a range of administration times.  

The need to ensure accuracy of MAR documentation and document a specific time to administer medications was discussed with Staff 1 (Regional Director) on 01/07/22. She acknowledged the findings.

1 - Residents 1, 2, 3, 4, 5, and 7 medication times were changed to be reflective of adminstration times and not range of times.

2 - PCC restrictions made to med pass times to not allow for ranges. Inservice provided to RCC regarding proper order confirmation

3 - Audit times for accuracy in PCC monthly as a part of QA process

4 - RCC's responsible  

Based on interview and record review, it was determined the facility failed to ensure an accurate TAR with documentation of administration and specific treatment orders by a legally-recognized practitioner was provided for 1 of 3 sampled residents (#1) who received wound care treatments. Findings include, but are not limited to:

Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia.

* Resident 1's progress notes, reviewed from 10/08/21 through 01/04/22, documented wound care was provided by facility staff to a head laceration and multiple skin tears; and

* On 11/23/21, there was a physician order for soaking a toe twice daily and applying antibiotic cream and a bandage for 7 - 10 days.   

The 11/01/21 through 01/04/21 TARs were reviewed. The orders for wound care (skin tears, cuts, lacerations, etc.) had not been transcribed to the TAR, and there was no documentation by staff of any of the treatments provided.

The lack of a documented treatment record for Resident 1's wound care was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident #1 treatment area assessed and recap note made

2 - Inservice to be completed with DHS/RN, RCCs, Program Director, Med Techs assuring all treatment orders and wound care is transcribed into the TAR per MD orders

3 - ED, DHS/RN, RCCs to review all skins and treatment orders during 24 hour process and assure transcription accuracy Mon-Fri during 24 hour process

RCC/DHS/ED responsible  

Based on interview and record review, it was determined the facility failed to ensure a resident who self administered an inhaler was evaluated at least quarterly to ensure the ability to self administer medications for 1 of 1 sampled resident (#4). Findings include, but are not limited to:

Resident 4 was admitted to the facility in October 2012 with diagnoses including chronic obstructive pulmonary disease.

A physician order noted the resident was able to self administer an albuterol inhaler PRN every six hours. Staff 3 (RCC) verified the use of the inhaler.

There was no evaluation of the resident's ability to safely administer the inhaler and keep it in his/her room.

In an interview on 01/05/22 at 2:20 pm, Staff 2 (RN) indicated she was aware the resident had an order to self-administer her/his inhaler and had not yet completed an evaluation of the resident's ability to self administer medications.

The need to complete evaluations of a resident's ability to self administer medications at least quarterly was discussed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident #4 self med eval was completed for PRN inhaler use. A complete audit of all resident medications including ability to self-administer and evaluations to be completed by compliance date.

2 - Inservice staff on the need for self-med evals for any resident who resides in RCF, who to notify, and proper physcian's order required.Review of evals to be done quarterly in conjunction with the service plan process

3 - Will review 2 resident evals per quarter as part of the internal QA process  

RCC/RN/ED  responsible  

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 10,11 and 12) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Facility training records were reviewed with Staff 16 (Regional Director of Operations) on 01/05/22. The following deficiencies were revealed:

1. Staff 10 (MC CG) hired 11/16/21 lacked documented evidence of the following pre-service orientation topics:

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

2. Staff 11 (MC CG) hired 11/25/21 lacked documented evidence of a written job description.

3. Staff 12 (CG) hired 12/02/21, lacked documented evidence of the following pre-service orientation topics:

* Abuse reporting requirements;

* Fire safety and emergency procedures; and

* Written job description.

The need to ensure all required pre-service orientation was completed prior to newly hired direct care staff beginning their job responsibilities was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Audit all employee files for the presence of all required preservice orientation items including fire/life safety, universal precuations, written job description etc.

2 - New employee onboarding process to be reviewed with BOM and assure that new hire checklist is completed and accurate for all new employees

3 - Master training grid to be used to track all employee training hours, and competencies. Once all employee files have been audited, ED to audit 3 files/month for accuracy and completeness.

Audit findings to be brought to internal QA meeting

4 - ED and BOM responsible

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 10, 11 and 12) demonstrated satisfactory performance in all assigned areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 16 (Regional Director of Operations) on 01/05/22 and revealed the following:

1. Training records for Staff 10 (MC CG) hired on 11/16/21 lacked documented evidence competency was demonstrated in the following areas:

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

2. Training records for Staff 11 (MC CG) hired on 11/25/21 lacked documented evidence competency was demonstrated in the following areas:

* General food safety, serving and sanitation; and

* First Aide/Abdominal thrust.

3. Training records for Staff 12 (CG) hired on 12/02/21 lacked documented evidence competency was demonstrated in the following areas:

* Role of the service plan in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First aide/abdominal thrust.

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1) Audit all employee files for the presence of required pre-service dementia training in all topics required by OAR's

2) New Onboarding check list will be utilized to ensure employees complete the required onboarding process

3) Master Training Grid will be used to track and audit trainings. Once all current employee files are in compliance, an audit of 3 employee files will be conducted monthly for ongoing compliance

4) BOM and ED responsible

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Facility fire drill records dated 07/2021 through 10/2021, were reviewed on 01/05/2022. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:

* Location of simulated fire origin;

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuated.

In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months.

The need to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months, was discussed with Staff 1 (Regional Director) on 01/05/22. She acknowledged the findings.

1 - Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director

2 - Fire drills to be conducted on company standardized forms which address all needed requirements per OAR

3 - Fire drills/training to be reviewed during internal QA meeting to assure compliance

ED responsible

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training included all required components. Findings include but are not limited to:

Facility fire and life safety records dated 07/2021 through 10/2021, were reviewed on 01/05/22 and revealed the facility lacked documented evidence of the following:

* Evidence alternate routes were used during fire drills; and

* Staff provided fire evacuation assistance to residents from the building to a designated point of safety.

The need to ensure fire and life safety training included all required components was discussed with Staff 1 (Regional Director) on 01/05/22. She acknowledged the findings.

1 - Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director

2 - Fire drills to be conducted on company standardized forms which address all needed requirements per OAR

3 - Fire drills/training to be reviewed during internal QA meeting to assure compliance

ED responsible  

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 01/04/22, multiple resident rooms including, but not limited to, 209 and 231, had stains, black marks and worn carpets.

A tour of the environment was conducted with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings and stated the facility had identified a list of rooms needing carpet replacement and the facility planned to do the replacements.

1) Rooms 209 and 231 resideng carpet has been identified for cleaning, repair or replacement.

2) Administrator, maintenance and housekeeping will do a weekly walkthrough utilizing the environmental QA form.Work order binder to be brought to stand up daily to review and assure items are being addressed

3) The weekly audits will be reviewed at QA for trends and QAPI opportunities

4) ED responsible

Based on observation and interview, it was determined the facility failed to ensure exit door alarms were functioning to alert staff when residents exited the RCF and provided a working call system in toilet and bathing facilities used by residents and visitors. Findings include, but are not limited to:

1. Observations during the survey revealed multiple exit doors in the RCF had alarms installed but were not functioning.

2. Observation of the call system in shower rooms and visitor bathrooms on the second floor of the building showed the pull cords did not alert staff that they were activated.

A interview with direct care staff on 01/06/22 revealed the call lights in the shower rooms and visitor bathrooms did not alert staff or anyone in the building so staff could respond.

The need for a working call system and exit door alarms was discussed with Staff 1 (Regional Director) during a walk through of the facility on 01/06/22. She acknowledged the findings.

1 - Call system conversion in RCF to address exit door alarms, shower rooms and visitor bathrooms to I-Alert system

2 - Inservice of staff on the use of iAlert monitoring of exit doors, shower, and visitor bathrooms to occur.

3 - Review of call light times in shower rooms, exit doors and visitor bathrooms reviewed daily and monthly in internal QA meetings

ED responsible

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 231, C 240, C 370, C 372, C 420, C 422, C 513 and C 555.

See POC for C231, C240, C370, C372, C420, C422 C513, C555

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 252, C 260, C 270, C 303, C 305, C 310, C 315 and C 325.

SEE POC for C252, C260, C270, C303, C305, C310, C315 and C325

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutrition and hydration plans were developed and included in residents' service plans for 2 of  3 sampled residents (#s 2 and 5) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the memory care unit in December 2021 with diagnoses including dementia. Interviews with staff and the resident were conducted. Resident 2's medical record was reviewed.

On 01/05/22 at 10:05 am, Staff 10 (MC CG) confirmed the resident was on a pureed diet, needed meal assistance and preferred to take meals in his/her room. Staff 10 went on to report Resident 2 did not like the pureed diet and after taking one to two bites, often refused to eat the remainder of the meal. Staff 10 confirmed the resident was on nutritional supplements, received them up to three times a day and usually finished approximately one third of the serving. On 01/05/22 at approximately 1:30 pm, Staff 1 (Regional Director) stated she was on the unit on 01/02/22 during dinner and the resident ate about half of the creamy potato soup with the meal assistance she provided.  

On 01/05/22 at approximately 1:45 pm, Resident 2 confirmed not liking the food and s/he preferred soup and sandwiches.

Resident 2's 12/13/21 through 01/04/22 MARs were reviewed and revealed a nutritional supplement was added on 12/23/21 with directions to staff to offer if the resident's meal intake was less than 50%. All entries were blank.

There was no documented evidence of the resident's food preferences, where the resident preferred to eat meals and the meal assistance s/he required in the resident's service plan.

2. Resident 5 was admitted to the memory care unit in April 2021 with diagnoses including dementia. Observations were made, an interview with the resident's family member was conducted and medical records were reviewed.

On 01/04/22 at 11:22 am, a staff member was observed feeding Resident 5 a creamy, thick substance from a four ounce clear plastic container.

On 01/05/22 at 1:58 pm, the resident's family member reported the resident being lactose intolerant, historically not liking eggs and requested the facility to provide rice to the resident. The family member did not believe rice was provided since the request had been made. The family member also stated they took Resident 5 out to a meal each Sunday, the resident had a "healthy appetite" and usually finished all of the food, without assistance, on his/her plate. The family member went on to report the resident's current favorite foods. None of which were identified on the resident's current service plan.

There was no documented evidence of the resident's food and beverage preferences. The information in Resident 5's service plan was not accurate pertaining to where the resident preferred to eat meals and there was no indication Resident 5 needed meal assistance.    

The need to ensure residents' nutrition plans were individualized was discussed with Staff 1 and Staff 2 (RN) on 01/06/22. They acknowledged the findings.

1 - Resident 2 and 5 SP updated to address their food preferences.

2 - All resident service plans to address food likes, dislikes and meal preference - including assistance needed and where they prefer to eat.

3 - SP to be reviewed and updated quarterly unless otherwise needed, and preferences to be reviewed at that time with SP planning team

ED, DHS/RN, RCCs responsible

Based on observation and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 5) whose records were reviewed. Findings include, but are not limited to:

Resident 1, 2 and 5's service plans offered some historical information about the residents, however the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents to participate in group activities or assist with providing more individualized activities.

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Regional Director) on 01/06/22. She acknowledged the findings.

1 - Resident 1, 2 ,5  service plans corrected with an individualized activity plan as outlined in OAR

2 - Activity plans/evaluations will be updated quarterly per service planning process which will include addressing current ability to participate in activites, current preferences, etc

3 - Service Plans/Evals due are reviewed daily during 24 hour process . Will audit 2 activity service plans monthly as part of ongoing QA process

ED and Activity Director responsible

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked out of their rooms. Findings include, but are not limited to:

During the survey, observations of resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open residents' rooms.

On 01/04/22, an unsampled resident was observed trying to open their apartment door and stating, "it's locked, can you open it?" The resident was observed seeking out staff to unlock his/her door.

On 01/06/22, the need to ensure residents were not locked outside their rooms was discussed with with Staff 1 (Regional Director). She acknowledged the findings.

1 - Resident service plans will be updated to reflect preference and ability for door to be locked in their presence or absence.

2 - Residents with the ability to maintain use of a key will be provided a key or mechanism for a key for their rooms. Evaluations will be completed and/or preferences made known in their service plan

3 - Quarterly as part of the service planning process

ED responsible