Print Inspection: 4N01

The findings of the change of ownership survey, conducted 03/04/24 through 03/07/24, 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 for 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 revisit to the change of ownership survey of 03/07/24, conducted 08/26/24 through 08/28/24, 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 for 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 second re-visit to the change of ownership survey of 03/07/24, conducted 11/21/24, 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.

3. Resident 1 moved into the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and type 2 diabetes mellitus.

A review of Resident 1's progress notes and interim service plans (ISPs), from 02/06/24 through 03/04/24, identified the following:

A progress note dated 02/16/24 indicated the resident sustained a skin tear on the top of his/her left hand. This constituted an injury of unknown cause.

On 03/05/24, Staff 2 (LPN) confirmed the facility had not completed an investigation or incident report to rule out abuse or reported the injury to the local SPD office if abuse or suspected abuse could not be ruled out.

The need to ensure injuries of unknown cause were promptly investigated to rule out abuse or neglect was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN). They acknowledged the findings, and no additional documentation was provided.

Based on interview and record review, it was determined the facility failed to ensure all resident incidents were promptly investigated to rule out abuse and/or neglect, investigations included documentation of follow-up action taken, and incidents were reported to the local SPD office if abuse and/or neglect could not reasonably be ruled out for 3 of 3 sampled residents (#s 1, 2, and 3) with incidents including unwitnessed falls and injuries of unknown cause. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 03/2023 with diagnoses including dementia and failure to thrive.

A review of Resident 2's progress notes, dated 12/18/23 through 03/04/24, and incident reports and interim service plans (ISPs) for the same time period identified the following:

A progress note dated 02/21/24 noted the resident's left outer and inner thigh had discoloration. This constituted an injury of unknown cause.

There was no documented evidence the facility completed an investigation to rule out abuse or report to the local office if abuse or suspected abuse could not be ruled out.

On 03/07/24, the need to ensure all injuries of unknown cause were investigated to rule out suspected abuse, or reported to the local office if suspected abuse could not be ruled out, was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

2. Resident 3 moved into the facility in 07/2022 with diagnoses including dementia.

The service plan, dated 01/17/24, noted Resident 3 required one-person assist for walking with a gait belt. The service plan also noted Resident 3 was a high risk for falls with the following fall interventions in place: staff were to ensure his/her room was clutter free, provide frequent checks, HH PT referral completed, and twin bed was replaced with a full-size bed.

Review of the resident's charting notes, dated 12/03/23 through 03/04/24, and incident reports and interim service plans (ISPs) for the same time period identified Resident 3 had 11 unwitnessed falls.

The facility provided investigations of the falls; however, the investigations failed to document what follow-up actions were taken and if the service-planned fall interventions were in place at the time of the unwitnessed falls, to reasonably conclude suspected abuse in the form of neglect was ruled out.

On 03/06/24, the need to ensure all investigations of incidents included and documented what follow-up action was taken, ensured the service-planned interventions were being followed at the time the incident occurred, and suspected abuse was ruled out or the incident was reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

Reporting/investigating abuse;

1. Resident #2 Incident report completed for 2/21 discoloration including notifying of family, pcp and nurse. Abuse and neglect ruled out. Resident #3 all Incident reports reviewed and updated with interventions, abuse ruled out and ISP in place for all falls. Resident #1 incident report filled out however investigation not completed due to discharge from facility on 3/6/2024  

2. LN/RCC were new and educated on incident reports and investigations.

Med Aid training on incident reports/interventions and TSP as well as policy reviewed done 3/25/2024.

RCC/LN/ED to read 24/72 hour report daily to ensure all incidents are identified and documented/investigated throughly.

All incident reports must be electronically signed off by RCC/LN/ED within 24/48/72 hours of incident to ensure abuse/neglect ruled out. Locked in PCC and investigation completed within 5 days of incident.

4. ED/WD/RCC to audit the process and monitor

Based on observation, interview, and record review, it was determined the facility failed to ensure unwitnessed falls with injuries were promptly investigated to rule out abuse and neglect or reported to the local SPD office as suspected abuse for 1 of 2 sampled residents (# 5) reviewed with reportable incidents. This is a repeat citation. Findings include, but are not limited to:

Resident 5 moved into the memory care community in 02/2023 with diagnoses including unspecified dementia.

The resident's service plan last updated on 06/25/24, temporary service plans, incident reports, progress notes from 05/10/24 through 08/05/24, observations of the resident, and interviews with care staff identified the following:

a.  Resident 5 was observed to walk without assistive devices and unassisted by staff multiple times during the survey from 08/26/24 through 08/27/24. Resident 5 had a shuffled and unbalanced gait and wore non-skid socks throughout the survey observations.

b.  Resident 5's service plan and temporary service plans noted the following fall interventions:

* Wear proper footwear;

* Wear well fitted clothing, make sure pants were fastened and belt was on properly;

* Clutter free environment;

* Remove furniture from fall space;

* Frequent safety checks;

* Watch for (the resident) carrying (his/her) cane and not using it properly;

* Cue to use the bathroom and escort to meals and activities;

* Two-hour toileting schedule; and

* Walk with him/her at all times.

c.Resident 5 had the following falls:

* 05/17/24: Unwitnessed fall;

* 05/28/24: Unwitnessed fall in the resident's room;

* 05/28/24: Second unwitnessed fall on the same day; in the resident's room;

* 06/08/24: Witnessed fall with four skin tears to the left elbow;

* 07/01/24: Witnessed fall in the hallway that resulted in pain requiring PRN morphine to be administered;

* 07/11/24: Unwitnessed fall resulting in a skin tear to the right arm;

* 07/19/24: Unwitnessed fall in the resident's room which resulted in injuries to the head and a open wound to the left forearm; and

* 07/22/24: Unwitnessed fall in the resident's room which resulted in redness to the right side of the forehead.

The facility investigations for the above falls failed to determine if the service planned fall interventions were being implemented at the time the falls occurred therefore, the facility was not able to reasonably rule out suspected abuse and was required to report the falls to the local SPD office.

In an interview with Staff 1 (ED) on 08/28/24 at 2:15 pm, the facility had not reported any of the above falls to the local SPD office. Survey requested the facility to self-report the above falls. Verification was received prior to survey exit on 08/28/24.

The need to ensure a prompt facility investigation reasonably concluded and documented the falls were not the result of suspected abuse was discussed with Staff 1 (ED) and Staff 21 (Vice President of Operations) on 08/28/24 at 2:15 pm. They acknowledged the findings.

1. Actions to Correct the Rule Violation:

A thorough review of the policies and procedures related to incident reporting, investigation, and abuse prevention will be conducted.

Immediate re-education and training for all staff on proper reporting procedures for unwitnessed falls, injuries, and suspected abuse to ensure timely reporting to the local SPD office.

A dedicated in-service training will be scheduled for all staff, focusing on the identification of abuse, mandatory reporting protocols, and the investigation process.

Incident reporting forms will be updated to ensure thorough documentation, including time, date, place, and individuals present during the event, as well as interventions in place at the time.

Immediate re-assessment of Resident 5's care plan to include specific interventions aimed at preventing future incidents.

2. System Corrections to Prevent Recurrence:

The facility's policies and procedures will be revised to include clear guidelines for investigating unwitnessed falls and injuries of unknown origin, ensuring that abuse or neglect is promptly ruled out.

A tracking and auditing system will be implemented to ensure that all incidents involving injury or potential abuse are reported, investigated, and resolved within the required timeframe.

A designated "Incident Response Team" will be established to review all reportable events and verify that proper reporting and investigations have been conducted. The team will meet weekly to review any new incidents.

A detailed checklist will be incorporated into the investigation process, ensuring that all steps (staff response, follow-up action, and administrator review) are documented thoroughly.

3. Frequency of Evaluation:

The system will be evaluated monthly for the first six months by the facility's management team. This includes audits of incident reports, resident care plans, and follow-up actions to ensure compliance with the rule.

After six months, quarterly audits will be conducted to ensure continued adherence to reporting and investigating requirements.

4. Responsible Staff for Completion/Monitoring:

The Executive Director will be primarily responsible for overseeing the correction process and ensuring that policies are implemented and followed.

The Resident Care Coordinator will monitor incident reporting and investigations, ensuring timely reporting to SPD, AAA, or law enforcement when required.

The newly formed Incident Response Team will be responsible for the continuous review of incidents and adherence to the revised procedures. This team will include the Executive Director, Wellness Director, and Resident Care Coordinator.

This corrective action plan aims to ensure that all incidents, especially those involving potential abuse or unwitnessed injuries, are properly reported and investigated to protect the residents and prevent future violations.

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

Observations of the facility kitchen, food storage areas, food preparation, and food service on 03/04/24 and 03/05/24 revealed the following areas in need of cleaning or repair:

* The faucet located above the three-compartment sink in the dish area and the faucet located to the left of the stove were constantly dripping;

* The wall located to the right of the stove had exposed dry wall present, thus making it an uncleanable surface; and

* The heating unit, directly above the food on the steam table, was rusted.

The need to ensure the kitchen was maintained in accordance with the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 19 (Director of Dining Services) on 03/05/24. They acknowledged the findings.

2 faucets were ordered 3/18/2024 and will be installed upon arrival from HD supply Installation will be completed prior to 5/6/2024

Exposed drywall was covered with FRP 3/7/2024

Rusty heating unit deep cleaned and repaired completed 3/25/2024

Dietary Director will do weekly rounds (no set day of the week assigned) to ensure kitchen is operating correctly with no maintenance issues. And input any mainteance issues into the TELS system. CBC kitchen audit form given to Dietary Director to use as weekly round tool and will turn into ED Thursdays at the end of his work week.

Dietary Director will ensure all needed repairs are done in a timely fashion. ED will monitor TELS to make sure repairs are in process and completed as well as weekly maintenance rounds in the kitchen

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain syndrome.

A review of Resident 1's move-in evaluation, dated 01/31/24, identified the facility failed to address the following required elements:

* Spiritual preferences and traditions;

* Mental health issues, including history of treatment and effective non-drug interventions; and

* Pain, including non-pharmaceutical interventions and how a person expresses pain or discomfort.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Resident move in and Eval;

Resident #1 unable to edit closed pre admission evaulation however confirmed that spiritual preference, mental health, pain was on service plan from admission and information available to staff.

1. RCC & LN were new and had not been trained on Move in evaluations and necessary information. Training done 3/25/2024

2. Move in evaulation will be re-evaluated and form will prompt required information to meet OAR

3/4. Each new move in will be reviewed by ED day of admission for any issues, indefinitely.  

3. Resident 1 was admitted to the MCC in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and type 2 diabetes mellitus.

Observations of the resident, interviews with staff, and review of the resident's service plan, dated 01/31/24, and interim service plans and progress notes from 01/31/24 through 03/04/24 were completed.

a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident and communication of the determined actions or interventions to staff on all shifts:

* 02/16/24 - Skin tear to left top hand; and

* 02/28/24 - Difficulty swallowing, throat pain, and "feeling under the weather."

b. The following short-term changes of condition lacked communication of the determined actions or interventions to staff on all shifts and documentation of progress noted at least weekly through resolution:

* 02/06/24 - Excoriation/abrasion on the left glut.

The need to ensure actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift, and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate, determine and document what action or interventions were needed for short-term changes of condition, communicate the actions and/or interventions to staff on each shift, monitor the condition at least weekly, with progress noted until the condition resolved, and/or failed to monitor residents consistent with their evaluated needs or service plans for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 03/2023 with diagnoses including dementia and failure to thrive.

Resident 2's progress notes, dated 12/18/23 through 03/04/24, incident reports and interim service plans (ISPs) for the same time period, and service plan, dated 01/16/24, were reviewed during the survey.

The following changes of condition lacked documented evidence the facility evaluated and determined what action or intervention was needed for the resident's condition, communicated the resident's condition to staff on each shift, and/or monitored the condition at least weekly through resolution.

* 12/18/23 - Pain in rectum;

* 12/28/23 - "Suspecting a UTI" [urinary tract infection];

* 01/30/24 - "Collect urine sample to rule out UTI";

* 01/31/24 - Chest scan identified a small spot of pneumonia and a new antibiotic would be prescribed;

* 02/01/24 - New medication furosemide;

* 02/06/24 - Blood blister 2x2 cm; and

* 02/21/24 - Discoloration to the outer and inner left thigh.

The need to ensure the facility evaluated, determined actions or interventions needed, communicated the actions/interventions to staff on each shift, and monitored the condition through resolution was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

2. Resident 3 moved into the facility in 07/2022 with diagnoses including dementia.

The service plan, dated 01/17/24, noted Resident 3 required one-person assist for walking with a gait belt. The service plan also noted Resident 3 was a high risk for falls with the following fall interventions in place: staff were to ensure his/her room was clutter-free, provide frequent checks, HH PT referral was completed, and twin bed was replaced with a full-size bed.

The following evaluated conditions lacked documented monitoring and review of the interventions for effectiveness:

* Resident 3 had 12 falls from 11/26/23 through 03/01/24.

There was no documented evidence the facility evaluated each subsequent fall to determine what actions or interventions was needed, communicated the actions or interventions to staff on each shift, reviewed previous fall interventions for effectiveness, and monitored the resident's condition, with progress noted at least weekly, until resolved.

The need to ensure residents were monitored per their evaluated care needs, the determined actions or interventions were reviewed for effectiveness, changes of condition were communicated to staff, and conditions were monitored at least weekly until resolved was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/06/24. They acknowledged the findings.

Change of Condition;

Resident #2 Follow up documentation to reflect no further concerns regarding pain, UTI, ISP now in place for new medications, foot blisters and  COC/nursing assesment completed 3/13/2024

Resident #3 RCC/LN resolved all incidents and alert charting with follow up notes addressing each incident. Resolved all falls and updated service plan to relect all interventions in place.

Resident #1 discharged 3/6/2024 no further documentation initated, completed or needed

1.Complete audit done of potential change of conditions and added to COC log and RN assesement initiated.

2.Implementation of Alert Charting and Audit Tool log 3/11/2024 to assist Staff in communication to nursing for possible coc, assists in keeping track of documentation needed and time frames they need to be completed in. This will be brought to daily stand up for review by clinical team. RCC/LN/RN trained and initated forms 3/11/2024

3.Initated Change of condition Audit tool/form that RN/RCC/ED will meet weekly on Thursdays to review

4. ED/RN

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced a significant change of condition related to weight gain. Findings include, but are not limited to:

Resident 2 moved into the facility in 03/2023 with diagnoses including hyperlipidemia, hypertension, and unspecified dementia. The resident was identified during the acuity interview as having had weight changes.

The resident's current service plan, dated 01/16/24, and weight records dated 11/07/23 through 02/20/24 were reviewed, observations were made, and interviews were conducted during the survey.

On 03/04/24 the resident was observed to remain in bed from 8:00 am to 4:30 pm. A caregiver was observed feeding the resident soup while s/he remained in bed.

During an interview on 03/06/24 at 5:30 pm, Staff 4 (RCC) reported the resident ate 100% of dinner meal.

Review of the resident's monthly weight records from 11/07/23 through 02/20/24 showed the following:

* 12/07/23 - 167.1 pounds;

* 01/07/24 - 162.1 pounds;

* 02/07/24 - 175.2 pounds

* 02/20/24 - 180.2 pounds; and

* 03/06/24 - 166.2 pounds (obtained during survey).

The surveyor was unable to verify the weight with a re-weigh because the resident was tired and requested to be transferred to his/her bed. Later that same day the resident was transported to the hospital.

From 01/07/24 to 02/07/24, the resident gained 13.1 pounds, which constituted a severe weight gain of 7.477 % in one month. This weight gain represented a significant change of condition and required an RN assessment.

There was no documented evidence an RN completed an assessment which documented and included findings of the assessment, resident status, and interventions made as a result of the assessment and updated the plan of care as appropriate.

On 03/07/24 the need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN). They acknowledged the findings.

Resident Health Services;RN assesment

Resident #2 COC/nursing assesment completed 3/13/2024

1. Nursing assesments completed on all COC identified 3/8/2024

2. Initated COC log to 3/11/2024 to prompt/assist RN to complete assessments timely. RN/RCC/ED/LN met to train and initated on 3/13/2024

3. Log will be reviewed in clinical stand up daily by RCC/ED and Weekly COC meetings on Thursday with clinical team.

4. ED/RN

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside providers and have policies to ensure outside service providers left written information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care for 1 of 1 sampled resident (#3) who received home health services. Findings include, but are not limited to:

Resident 3 moved into the facility in 07/2022 with diagnoses including dementia and repeated falls.

During the acuity interview on 03/04/24, Staff 2 (LPN) reported Resident 3 had frequent falls and was receiving HH PT services.

Review of the resident's clinical record, including interim service plans (ISPs), current service plan, and charting notes dated 12/18/23 through 03/04/24 identified the following:

* On 12/28/23 the facility sent a request for HH PT/OT to evaluate and treat weakness and help with transfers. The physician signed the order on the same day;

* On 01/24/24 the physician signed a second order for HH PT referral; and

* On 02/20/24 there was a HH PT provider note left at the facility.

There was no documented evidence HH PT/OT left any additional information in the facility that addressed the on-site services provided to the resident and any clinical information necessary for facility staff to provide supplemental care.

During an interview on 03/06/24, Staff 2 reported the facility didn't have the initial evaluation and plan of care from the HH PT/OT; however, she confirmed the resident was receiving home health services. Additionally, it was reported the facility was having difficulty with the provider leaving notes after the visits.

On 03/06/24, a home health service provider was observed meeting with the resident.

On 03/07/24, the need to ensure outside service providers left written information in the facility that addressed the on-site services being provided to the resident and any clinical information necessary for the facility staff to provide supplemental care was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN). They acknowledged the findings.

Outside provider coordination;  

Resident #3 Plan of care received from HH company and intergrated in to service plan

1. All residents with outside providers will be audited and brought into compliance with TSP/Service planning and updated notes by 3/29/2024.

2.RCC/LN/ED have initiated an outside provider tracking log which prompts TSP/ISP, f/up and charting. Also educating all outside providers to fill out visit slips when in house with any new recommendations.

3.This log will be reivewed in daily clinical rounds to ensure the RCC/LN/ED are aware and correct documentation is in place

4.Monthly spot audits by ED/LN to ensure compliance indefinitley

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment, which included implementing protocols to prevent the development and transmission of communicable diseases. Findings include, but are not limited to:

During the acuity interview conducted on 03/04/24 with Staff 2 (LPN), the facility identified several residents with suspected respiratory illness and/or symptoms of unknown pathogen.

a. Per Oregon Health Authority Summary of Long-Term Care Facility Infection Control Policies for Other Respiratory Pathogens, facilities were required to ensure:

* "Staff caring for residents with suspect or confirmed respiratory pathogens are required to wear a fit-tested N 95 respirator or surgical mask, eye protection, gown, and gloves."

b. Observations of staff during the survey, from 03/04/24 through 03/07/24, identified multiple instances where staff failed to wear a surgical face mask when providing resident care to the residents who were identified with respiratory illness and/or symptoms that had not been evaluated to determine the symptoms were not communicable.

Additionally, multiple symptomatic residents were observed dining in groups and participating in group activities with asymptomatic residents.

The need to ensure the facility implemented and maintained infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was reviewed with Staff 1 (ED), Staff 2, Staff 3 (RN), and Staff 20 (Infection Control Specialist) on 03/06/24. They acknowledged the findings.

Infection control

1. Physician visited and evaluated sample residents 3/7/2024 and gave facility infection control guidance at that time. Infection process ruled out on 2 of the other sample residents

Staff trained on infection control policy 3/25/2024

LN completed OCP/ICS training 3/27/2024 to provide onsite ICS vs off site ICS which had been the practice prior.

Chronic conditions such as cough/chf/copd will be service planned in the future to assist un liscensed staff in identifying new infectious process vs long standing chonic condition.

New reported potential infectious symptoms willl be reported to RCC/LN immediatley

Evaulation of systems will be done with any new onset of symptoms or illness.

2. Resident 2 moved into the facility in 03/2023 with diagnoses including hyperlipidemia, hypertension, and unspecified dementia.

Review of the resident's 02/01/24 through 03/06/24 MARs and current prescriber orders identified the following medication was not carried out as prescribed:

Aspirin 81 mg, give one tablet per day had been discontinued on 03/01/24; however, the medication had been transcribed on the March 2024 MAR and was being administered from 03/02/24 through 03/06/24.

The need to ensure the facility had current orders for all medications the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 2 (LPN) on 03/07/24. They acknowledged the findings.

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

1. Resident 1 was admitted to the facility in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain syndrome.

Resident 1's current physician orders and MAR, dated 02/01/24 through 02/29/24, were reviewed and revealed the following:

The resident had physician orders dated 02/15/24 for the following medications:

* Acetaminophen 325 mg - Take two tablets by mouth every four hours as needed for pain and/or fever over 101 degrees. If ineffective after one hour, may give oxycodone for severe pain;

* Oxycodone 5 mg - Take one tablet by mouth every six hours as needed for moderate pain. Must try Tylenol first, then if ineffective after one hour, may use oxycodone; and

* Lidocaine 5% patch - Place one patch onto the skin every day for 12 hours on and remove for 12 hours (for leg pain).

a. Between 02/15/24 and 02/29/24, Resident 1's MAR indicated the resident was administered oxycodone prior to or instead of acetaminophen on seven occasions. The facility failed to ensure physician written parameters were carried out as prescribed.

b. Between 02/21/24 and 02/25/24, the resident's Lidocaine patch was documented as not available and was not administered on five occasions. The facility failed to ensure physician orders were carried out as prescribed.

On 03/06/24 at 3:01 pm, the surveyor and Staff 10 (MT) reviewed the electronic MAR and medication supply. Staff 10 confirmed the Lidocaine patch was not administered because the medication was not available.

The need to ensure all medications were carried out as prescribed and written was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Medication orders;

Resident #1 discharged 3/6/2024 no follow up available

Resident #2 Reconciled hospital orders and pcp orders to reflect correct medications 3/6/2024

1. MAR/TAR reviewed/audited and corrected, physicians notified and pharmacy contacted for issues identified during survey process. Education provided to all Med Aids regarding provider orders.

2. Daily review of dashboard in PCC to identify MAR discrepencies and RCC to verify notification of PCP and LN.

3. Weekly MAR to CART audits, Weekly missed med reports to be ran and audited by LN/RCC Quarterly eval by pharmacist at Consonus

4.Quarterly pharmacy review third party to monitor

Based on observation, interview, and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT and documentation of the use of the device was included in the resident's service plan for 1 of 2 sampled residents (#1) who had side rails. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 02/2024 with diagnoses including nontraumatic intracerebral hemorrhage (brain bleed) and chronic pain.

Resident 1 was observed to have a hospital bed with full side rails. The side rails at the head of the bed were elevated throughout the survey. The side rails at the foot of the bed were in the lowered position during all observations.

There was no documented evidence the following required elements were completed:

* Assessment by an RN, PT, or OT; and

* Documentation of the use of side rails in the resident's service plan.

On 03/07/24, Staff 2 (LPN) confirmed she had completed the resident's "Supportive Devices with Restraining Qualities Assessment."

The need to ensure the use of a supportive device with potentially restraining qualities was assessed by an RN, PT, or OT, and was included in the resident's service plan, was discussed with Staff 1 (ED), Staff 2, and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

RN assessment of side rails done 3/6/2024 for sample resident that was still in house #2 Resident #1 discharged 3/6/2024.

RN will do all side rail assessments moving forward, LN educated that it is not in her scope of practice.

Will be evaluated on admission, quarterly and with COC.

RN/ED to monitor indefinetly

Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

On 03/05/24 and 03/06/24, fire and life safety records, dated 08/2023 through 02/2024, were reviewed. The fire drill records lacked the following components:

* Escape route used;

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

* Evacuation time-period needed;

* All staff members on duty and participating; and

* Number of occupants evacuated.

Due to the escape route not being documented, there was no evidence alternative routes were used during fire drills.

Additionally, any problems encountered with residents being resistive to participate in drill were not documented; thus, the facility was unable to determine if the evacuation standard had been met.

The need to ensure fire drills included documentation of all required elements was discussed with Staff 1 (ED) on 03/06/24. She acknowledged the findings.

Fire Drills;

A new Fire Drill record/form implemented that has all necessary information on it to meet OAR

Meeting with Fire Marshall 3/21/2024 to establish evacuation routes

Evaulation will be monthly after each fire drill is conducted to ensure complaince by Maint. Director and ED who will sign off on the new fire drill form

Quarterly audit to be completed by Corp Maint. Director

Based on observation, interview and record review, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 231.

Refer to C 231.

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

The interior of the MCC was toured on 03/04/24. The following areas were observed to need cleaning and/or repair:

* Benches throughout the MCC were stained and had scrapes or gouges in the wood;

* Armchairs near room 5 were stained, fabric was faded, and the wood had scrapes or gouges;

* Side table near room 5 had gouges in the finish, chipped paint, and a spill which was sticky to the touch;

* Armchairs in the activity room were stained and had frayed and worn fabric; and

* Dining chairs throughout the MCC had staining and food debris/spills.

The environment was toured with Staff 1 (ED) and Staff 4 (RCC) on 03/05/24. The findings were discussed again with Staff 1, Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the above areas needed to be cleaned and repaired.

Benches shampooed 3/15/2024 legs repaired and re-stained

Dining chairs cleaned 3/6/2024

Torn/damaged activity stackable chairs removed and discarded 3/25/2024

Order placed for new side tables (the sticky residue is the varnish coming off due to multiple cleanings) arm chairs 3/25/2024 from Direct Supply

Based on observation and interview, it was determined the facility failed to ensure a one-way flow of soiled laundry to preclude potential contamination and to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:

A tour of the laundry facilities throughout the MCC and interviews with staff between 03/04/24 and 03/07/24 revealed the following:

The facility had two laundry rooms where linens were washed. Soiled linens were cleaned in a separate room across from the "Dirty Utility Room" (DUR). The DUR laundry room had two doors leading to the hallway and a single residential washing machine with no indicator of rinse temperature. On 03/05/24, Staff 10 (MT) reported facility staff only used the door directly across from the DUR to bring in soiled linens and take out clean laundry.

Throughout the MCC, interviews with both housekeeping and caregiving staff indicated the facility used a single laundry detergent with no other chemicals added when laundering all linens. During the walk-through with Staff 1 (ED) on 03/05/24, she confirmed the rinse cycle for soiled linens does not reach the required temperature.

On 03/07/24 at 2:09 pm, Staff 7 (Housekeeping Supervisor) stated, "I looked into [whether the laundry detergent had a chemical disinfectant] and called our guy. It absolutely does not have a chemical disinfectant."

The need to ensure a one-way flow of soiled laundry to preclude potential contamination and to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 1, Staff 2 (LPN), and Staff 3 (RN) on 03/07/24. They acknowledged the findings.

Laundry Sanitizer

Ordered and installed by Auto Chlor 3/8/2024

On Contract with Auto Chlor to refill and maintain monthly

Housekeeping supervisor to double check monthly when Auto chlor here that the right product is delievered.  

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they were installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

The MCC was toured on 03/05/24 and an electric fireplace was observed in the dining room. The fireplace was on the high setting, and although the glass was cool to the touch, the fireplace had a heating element that produced a stream of hot air. The fireplace was located in a place where a resident could come into incidental contact with the fireplace and the hot air it produced.

The temperature of the hot air was measured on 03/05/24 with a digital thermometer on both the high and low setting with Staff 12 (MT/Care Partner) present. When the fireplace was switched to high, the temperature of the hot air reached above 190 degrees F. When the fireplace was switched on low, the temperature of the hot air reached above 135 degrees F. Staff 12 was instructed to ensure the heating unit remained off for resident safety. During additional observations, the heating unit remained off.

The need to ensure wall heaters and associated heating elements did not exceed 120 degrees F when they were installed in locations that were subject to incidental contact by residents was discussed with Staff 1 (ED) on 03/05/24 and again on 03/07/24. She acknowledged the findings.

Fireplace was immediately turned off and kept off until fireplace screen could be installed

Fireplace screen to be installed 3/28/2024 to ensure safe distance and barrier provided between heat coming from fireplace and residents. Fire place to be set to low and no higher at all times

Daily and weekly walkthroughs by RCC/Maint to ensure fireplace screen in proper position and in good repair

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 420, C 513, C 530, and C 540.

Please refer to c231, c240, c420, c513, c530, c540

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

Refer to C 231.

Refer to C 231.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired direct care staff (#s 14, 15, 16, and 17) completed all required orientation training topics within required timelines, 2 of 2 non-direct care staff (#s 5 and 18) completed infectious disease prevention training and 3 of 3 long-term direct care staff (#s 8, 10 and 11) completed a total of 16 hours of in-service training annually, which included annual infectious disease prevention training. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (ED) on 03/05/24. The following deficiencies were identified:

a. The following newly-hired direct care staff failed to complete orientation training for infectious disease prevention:

* Staff 14 (CG), hired 02/08/24;

* Staff 15 (CG), hired 02/09/24;

* Staff 16 (CG), hired 02/14/24; and

* Staff 17 (CG), hired 02/28/24.

b. The following long-term and/or non-direct care staff failed to complete infectious disease prevention at hire and/or annually thereafter:

* Staff 5 (Activities Director), hired 01/11/13; and

* Staff 18 (Housekeeping), hired 11/06/23.

c. The following long-term direct care staff failed to complete 16 hours of annual in-service training that included at least 10 hours of CBC provision of care topics and annual infectious disease prevention training:

* Staff 8 (MT), hired 02/15/21;

* Staff 10 (MT), hired 02/04/21; and

* Staff 11 (MT), hired 11/12/21.

The need to ensure newly-hired direct care staff completed all orientation training prior to beginning any job duties, all non-direct care staff completed annual infectious disease prevention training, and long-term direct care staff completed 16 hours of annual in-service training, which included at least 10 hours related to provision of care topics and annual infectious disease prevention training, was reviewed with Staff 1 on 03/05/24. She acknowledged the findings.

All staff are now current with education and will be monitored monthly to ensure complaince with education and will be pulled from caregiving if not completed timely to ensure edcaution is complete.

All new staff will not work on the floor with residents until all new hire education is completed as montiored by BOM with each new hire.

ED/BOM to monitor indefinetley

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 270, C 280, C 290, C 295, C 303, and C 340.

Refer to: C 252, C 270, C 280, C 290, C

295, C 303, and C 340.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. Findings include, but are not limited to:

The facility was endorsed as a secure Memory Care Community for residents with a diagnosis of dementia. The building and its residents had access to an outdoor recreation area.

The outdoor recreation area was toured on 03/05/24. There was a wooden fence surrounding the perimeter of the secured area, which was built on a hill. The fence had different height measurements based on the positioning on the hill, with areas near the dining room door and gazebo measuring below six feet.

The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet in height was discussed with Staff 1 (ED) on 03/05/24. She acknowledged the height of the fence was less than six feet in areas.

Fence boards cleared and re leveled to reach minimum 6 feet to be completed 4/25/2024

Based on observation and interview, it was determined the facility failed to individually identify residents' rooms to assist residents in recognizing their rooms. Findings include, but are not limited to:

The MCC was toured on 03/04/24 through 03/07/24. All resident units lacked a means to individually identify their rooms and assist the residents in recognizing their rooms.

On 03/06/24 and 03/07/24 an unsampled resident was observed being unable to locate his/her room and was standing in front of their unit door.

The need to ensure the memory care community individually identified residents' rooms to assist residents in recognizing their rooms was reviewed with Staff 1 (ED) on 03/05/24 and 03/07/24. She acknowledged the findings.

Personlized shadow boxes are in the process of being hung up and will be the Activitiy Directors repsonsiblitiy to fill and complete within 30 days of move in as able with family participation

LN/RCC to monitor with each new admission.