Print Inspection: 4RF1

The findings of the re-licensure survey conducted 02/06/23 through 02/09/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities 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

Based on observation, interview and record review, it was determined the facility failed to ensure incidents of abuse, suspected abuse or injuries of unknown cause were promptly investigated and reported to the local Seniors and People with Disabilities (SPD) office if abuse or suspected abuse could not be ruled out for 1 of 3 sampled residents (# 3) whose incident reports were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in January 2022 with diagnoses including dementia.  

The resident's service plan dated 11/28/22, observations of the resident and interviews with care staff between 02/06/23 and 02/09/23 identified Resident 3 had a recent decline in mobility and now required full assist with all ADL cares, two person assist for transfers and was using a wheelchair for mobility with staff assist.

Review of  the Skin Impairment and Wound Log, physician communications and progress notes from 11/02/22 through 02/06/23 showed the following:

* On 02/05/23 the Skin Impairment and Wound Log indicated the resident had a bruise on the chest.

During an observation on 02/06/23, Resident 3 was noted to have a dark purple circular bruise on the center of his/her upper chest.

On 02/07/23, Staff 1 (Administrator) stated there would be no way to rule out abuse for the bruise.

There was no investigation completed to reasonably rule out abuse, and the injury of unknown cause was not reported to the local SPD office.

The need to investigate resident incidents to rule out abuse and neglect and report to the local SPD as appropriate was discussed with Staff 1, Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 2/08/23. The staff acknowledged the findings.

Staff 1 was asked to report the injury of unknown cause to the local SPD office on 02/07/23 and provided confirmation of the report prior to survey exit on 02/09/23.

1. Administrator completed reports and sent prior to survey exit. Discussion was done with Administrator and staff on the importance of timeliness on incident reports and follow through with reporting to APS.

2. Elder abuse training will be conducted with staff by designated compliance date.

3. Will inservice staff at monthly meeting and correct issues immediately when observed or notified.

4. Senior Executive Director, Director of Health and Wellness, Memory Care Directors and Resident Care Director will be responsible for completion and monitoring.  

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services, and were implemented for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in January 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the service plan, dated 11/28/22, interim service plans and progress notes dated 11/02/22 through 02/06/23 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Two person assist with transfers;

* Use of wheelchair for mobility with assistance;

* Bed mobility assistance;

* Full assist for dressing;

* Skin conditions including instructions;

* Evacuation assistance needed;

* Continence of bowel and bladder, including assistance needed; and

* Drink supplements.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. The staff acknowledged the findings. No further information was provided.

4. Resident 4 was admitted to the facility in July 2019 with diagnoses including Alzheimer's disease and osteoarthritis of the knee.

During the acuity interview on 02/06/23, the facility identified Resident 4 as having a history of falls, some which resulted in injury.

Review of Resident 4's service plan dated 12/22/22, identified that Resident 4 was independent with transfers and ambulation, had a history of falls, displayed moderate forgetfulness, did not use the call light to ask for assistance and frequently required staff to orient the resident to time and place. The service plan instructed staff to "frequently check in on [him/her] during the night for safety" related to the resident's fall risk.

The service planned interventions, related to the resident's fall risk, did not provide clear direction to staff related to how frequently the staff should check on the resident during the night shift.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (LPN) on 02/07/23. They acknowledged the findings.

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

Observations of the resident, interviews with the staff and review of the resident's service plan, dated 01/27/23, interim service plans, and progress notes dated 11/08/22 through 02/02/23 were reviewed. The service plan was not reflective of the resident's current care needs and lacked clear direction to staff in the following areas:

* Full assistance with bathing/showering needs;

* Resistance to care behaviors and interventions;

* Resident specific instructions for providing toileting/incontinent care including how often;

* The resident's preference to have a male caregiver assist with toileting/incontinent care;

* Denture care and oral hygiene; and

* Relationship status with another resident.

The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 4 (RN) on 02/09/23. They acknowledged the findings.

3. Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, major depressive disorder, dysphagia, and anxiety disorder.

Review of the resident's most recent service plan, interviews with staff and observations of the resident showed the service plan did not provide clear direction to staff and/or was not implemented in the following areas:

* Mighty Shakes 3 times daily; and

* Level of assistance with eating.

The need to ensure resident service plans were implemented and provided clear direction to staff on the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

1. Will update Resident's service plans to reflect current status and provide clear direction to staff regarding the delivery of services.

2. Will ensure service plans are created and updated to reflect the Residents current status prior to move in, within 30 days, every 90 days thereafter or with any significant change of condition per company policy and Oregon State Rule.

3. Changes to service plans will be reviewed daily in clinical stand up meeting to ensure accuracy and appropriateness and make changes as needed.

4. Administration, nursing or designee will be responsible to see that the corrections are completed and monitored.

2. Resident 3 was admitted to the facility in January 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the resident's 11/28/22 service plan, interim service plans, current physicians orders and 11/02/22 through 02/06/23 progress notes were completed.

a. Resident 3 experienced multiple short-term changes, without actions or interventions determined and communicated to staff and/or documented weekly monitoring of progress until resolution related to the following:

* 11/10/22 Flu vaccine administered;

* 12/02/22 Itching all over with rash to inner thighs and chest;

* 12/16/22 and 12/30/22 Permethrin topical cream for treatment of scabies; and

* 01/28/23 Found on floor next to bed.

b. Resident 3's service plan dated 11/28/22 indicated the resident was independent with bed mobility, transfers, ambulation, toileting, dressing and eating.

Resident 3 was observed during survey to be assisted with meal intake, used a wheelchair with assist for mobility, was a two person transfers from wheelchair to bed and full assist with dressing and hygiene cares.

Staff reported the resident began to decline approximately two weeks ago, and now required two person transfer assist, was incontinent, needed full assist with all ADLs and meal assistance.

During an interview with Staff 4 (RN) on 02/06/23, she stated that she was unaware of the resident's significant decline in condition until 02/03/23. On 02/06/23 the RN completed an assessment for the significant change of condition.

The need to ensure there was documentation for short-term changes of condition which reflected an evaluation, monitoring of progress to resolution at least weekly, provided resident-specific directions to staff  and/or that significant changes of condition were reported to the RN was discussed with Staff 1 (Administrator),  Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 on 02/08/23. They acknowledged the findings.

3. Resident 4 admitted to the facility in July 2019 with diagnoses including Alzheimer's disease and osteoarthritis of the knee.

Observations, interviews with staff and review of Resident 4's clinical records including progress notes dated 10/23/22 through 02/06/23, evaluations, service plans, hospital discharge instructions and incident reports revealed the following:

Resident 4's service plan dated 12/22/22, identified Resident 4 was independent with transfers and ambulation, had a history of falls, displayed moderate forgetfulness, did not use the call light to ask for assistance and frequently required staff to orient the resident to time and place.

Review of Resident 4's clinical records identified the resident experienced the following changes of condition:

* On 11/03/22, staff documented Resident 4 had an unwitnessed non-injury fall. There was no documented evidence the facility determined resident specific interventions related to the resident's ongoing fall risk and there was no documented evidence the facility monitored the resident consistent with his/her evaluated and service planned needs related to previous fall risk interventions for frequent safety checks; and

* On 12/02/22, staff documented Resident 4 was found on the floor in his/her room. The resident stated s/he fell out of bed and hit his/her head. Staff noted a small cut above the resident's right eyebrow. There was no documented evidence the facility monitored the resident consistent his/her evaluated and service planned needs related to previous fall risk interventions for frequent safety checks.

The need to ensure residents who experienced changes of condition were monitored consistent with their evaluated and service planned needs and resident specific interventions were determined and documented was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

4. Resident 2 was admitted to the facility in November 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's service plan dated 01/27/23, interim service plans, and progress notes dated 11/08/2022 through 02/02/2023 were reviewed and revealed the following:   

* On 01/09/23, staff noted the resident was being very aggressive. Staff documented "[Resident 2] pushed another resident in a wheelchair and the resident almost fell out." Staff further noted they had stopped Resident 2 from hitting another resident who was sleeping in a recliner; and

* On 01/15/23, staff documented "[Resident 2] was sitting at a table in the dining room and was yelling Don't run over me, at a resident passing by in a wheelchair." Staff noted "[Resident 2] raised [his/her] hand in a fist as if [s/he] was going to hit the resident in the wheelchair." Staff documented they prevented Resident 2 from hitting the other resident.

The resident's behaviors represented short-term changes of condition. There was no documented evidence the facility determined resident-specific interventions or actions, communicated the interventions or actions to staff on all shifts, and monitored the conditions with progress noted at least weekly through resolution.

The need to ensure the facility communicated changes of condition including monitoring instructions and interventions to staff and documented progress, at least weekly, until the condition resolved was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 4 (RN) on 02/09/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to evaluate changes of condition, refer significant changes of condition to the facility nurse, determine actions or resident-specific interventions, document weekly progress noted until the condition resolved and/or failed to monitor residents consistent with evaluated needs and service plans for 4 of 4 sampled residents (#s 1, 2, 3 and 4) with changes of condition. Resident 1 experienced severe and ongoing weight loss.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, anxiety disorder, major depressive disorder, and dysphagia.

The resident's 11/02/22 through 02/05/23 progress notes, interim service plans (ISPs), practitioner orders, 11/01/22 through 02/05/23 MARs, and 08/09/22 through 02/06/23 weight records were reviewed. The following were identified in regards to weight loss:

On 10/01/22 the resident's primary care provider (PCP) ordered TID Mighty Shakes, and on 11/07/22 ordered weekly weights.

The following weights were provided:

* 08/09/22 130 pounds;

* 09/20/22 127.8 pounds;

* 10/06/22 128.2 pounds;

* 11/09/22 118.2 pounds;

* 11/17/22 115.7 pounds;

* 12/08/22 113.4 pounds;

* 12/12/22 112.8 pounds; and

* 01/12/23 109.4 pounds.

Between 10/06/22 and 11/09/22 the resident experienced a severe weight loss of 7.8%, or ten pounds in one month. Between 11/09/22 and 12/15/22 the resident lost an additional 5.4 pounds.  

Resident 1's noted weight loss constituted a significant change of condition.  There was no documented evidence the facility RN had assessed the weight loss to include review of findings, resident status, and interventions made as a result of the assessment.  

A 12/15/22 RN progress note stated: "[Resident] has had progressive weight lost [sic] over the last year. [S/he] gets boost shakes three times a day. [S/he] eats very little per staff. [S/he] is encouraged by caregivers and staff to eat at meals and is offered snacks at least twice a day. Put on weekly weights to track weight trends more closely. Will continue to work with PCP regarding weight loss and [his/her] needs."

The Resident's service plan, dated 01/27/23 stated s/he was independent with dining, and needed staff to ensure s/he was eating meals and snacks. The service plan also stated s/he was on a pureed diet.

On 01/16/23 the resident was admitted to hospice with a primary hospice diagnosis of "Unintentional Weight Loss."

An ISP dated 02/03/23 stated, "Needs assistance eating". No further instruction was documented.

In an interview with Staff 7 (CG), 02/06/23, she stated, "[Staff 12] put in a thing for us to feed [resident] because [s/he] eats it all if someone feeds [him/her]." In an interview with Staff 15 (CG) on 02/08/23, she stated, "When [s/he] sits at a table [s/he] likes, [s/he] stays seated more. When [s/he's] not you have to tell [him/her] to sit down and eat. You don't have to sit with [him/her]."

Observations of the resident at meals between 02/06/23 and 02/08/23 showed the resident was able to feed himself/herself and would typically stand up and walk off after finishing one of the three pureed food items. The resident was offered a health shake at lunch on 02/06/23 and at breakfast on 02/08/23. The resident was not offered a health shake at lunch on 02/07/23.

On 02/06/23 staff documented resident's weekly weight was 105.6, a 24.4 pound weight loss from 08/09/22, which constituted a severe overall weight loss of 18.8% in 6 months.

There was no documented evidence the facility evaluated the resident's initial and ongoing weight loss, or referred to the facility RN for assessment when the resident experienced a significant change of condition. There was no documented evidence weekly progress had been noted to monitor the effectiveness of the TID health shakes, or that weekly weights documented in the resident's chart had been evaluated.  

The failure of the facility to evaluate the resident's weight loss, provide TID health shakes as ordered, and monitor the interventions for effectiveness put the resident at risk for further weight loss.  

On 02/08/23 the surveyor requested Staff 4 to complete an assessment of the resident for weight loss, determine appropriate interventions, communicate them to staff, and ensure interventions were implemented.

The facility's need to ensure residents with severe weight loss were evaluated, interventions determined, and clear direction was provided to staff, with weekly monitoring noted was discussed with Staff 1 (Administrator) Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

1. Will conduct a focused review of residents  current overall health and functional abilities to ensure an appropriate plan of care is in place to effectively meet the residents needs.  

2. Staff will utilize the 24hr Communication book to communicate resident change in condition. Nursing will review the 24hr book and assess any resident identified as having a significant change of condtion. Nursing will assess the Resident weekly for effectiveness of interventions, need for additional interventions and follow up with MD on any noted concerns or recommendations. The weekly RN assessment will continue until the Residents health status returns to baseline or a new baseline can be established.  

3. The area needing correction will be evaluated to ensure resident change of conditions are communicated to nursing and interventions communicated to staff.

4. The Nurse or designee will be reponsible to see that the corrections are completed and monitored.  

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

Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, anxiety disorder, major depressive disorder, and dysphagia.

The resident's 11/02/22 through 02/06/23 progress notes, interim service plans (ISPs), practitioner orders, and 08/01/22 through 02/06/23 weight records were reviewed.

The following weights were provided:

* 08/09/22 130 pounds;

* 09/20/22 127.8 pounds;

* 10/06/22 128.2 pounds;

* 11/09/22 118.2 pounds;

* 11/17/22 115.7 pounds;

* 12/08/22 113.4 pounds;

* 12/12/22 112.8 pounds;

* 01/12/23 109.4 pounds; and

* 02/06/23 105.6 pounds.

The resident experienced ongoing weight loss as follows:

* A 10 pound loss from 10/06/22 to 11/09/22, which constituted a severe 7.8% loss in one month;

* An 18.6 pound loss from 10/06/22 to 01/12/23, which constituted a severe 14.7% loss in three months;

* A 12.6 pound loss from 11/09/22 to 02/06/23, which constituted a severe 10.66% loss in three months; and

* An overall 24.4 pound loss from 08/09/22 to 02/06/23, which constituted a severe 18.8% loss in six months.

Resident 1 experienced ongoing severe weight loss from November 2022 to February 2022.

There was no evidence the facility RN completed a significant change of condition assessment for the initial severe weight loss in November, or subsequent assessments when the resident continued to lose weight, which included documented findings, resident status, and interventions made as a result of the assessment.  

The facility's failure to ensure an RN assessment was completed for severe and ongoing weight loss put the resident's health and safety at risk.

Refer to C 270, example 1.

The need to ensure residents who experienced significant changes of condition were assessed by the RN was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. They acknowledged the findings. On 02/08/23 Staff 4 initiated a comprehensive assessment of the resident, which was implemented immediately.

1. DHW/RN to do Significant change and follow up weekly will be by DHW/RN or LPN designee.

2. DHW/RN in community full time and will conduct weekly meetings with LPN's.

3.DHW/RN will audit weekly.

4. DHW/RN with assistance and notification of the Clinical team.  

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside service providers for 1 of 1 sampled resident (#1) who received hospice services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, major depressive disorder, dysphagia, and anxiety disorder. During the acuity interview on 02/06/23 the resident was identified as receiving hospice services.

On 02/09/23 at 1:57 pm Staff 1 (Administrator) provided a hospice note dated 02/07/23 and reported she had just gotten off the phone with hospice who would be faxing over all the notes because "they haven't been leaving them." At 2:35 pm Staff 12 (MT) provided 8 outside provider notes, dated 01/16/23 through 02/03/23, which had been faxed from hospice services.

The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 on 02/09/23. She acknowledged the findings.

1. DHW/RN and Sr. ED will meet with each Outside provider to reducate them on the policies and procedure for providing visitation notes at time of visitation. Lpn's inserviced by DHW/RN.

2. Concierge will remind outside providers to fill out form, turn it in to Concierge. Concierge will ensure that it is scanned to Sr. ED, DHW/RN, LPN, RCD and/or MCD for the unit the visit was conducted in. These notes will be scanned daily to parties responsible for the corresponding unit for resident. Chart notes updated and any new recomendations are entered. RCD/MCD will follow up if visit documentation is not left for coordination of care.

3. Weekly Audits to ensure that notes are being entered.

4' DHW/RN, MCD, RCD and LPNs will oversee that MedTechs have entered notes and changes required have been reported and executed.    

2. Resident 2 was admitted to the facility in November 2022 with diagnoses including high blood pressure and dementia.

Resident 2's current physician orders and 01/01/22 through 2/06/23 MARs were reviewed.

A physician order dated 12/22/22 directed staff to administer atorvastatin 40 mg tablet by mouth every evening to lower cholesterol.

There was no documented evidence the order was transcribed onto the MARs and there was no documentation the atorvastatin was administered from 01/01/23 through 02/06/23.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), and Staff 4 (RN) on 02/09/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to carry out medication or treatment orders as prescribed for 2 of 4 sampled residents (#s 1 and 2) whose orders and MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, major depressive disorder, dysphagia, and anxiety disorder.

A Physician Order Sheet for Resident 1 dated 10/01/22 listed "Mighty Shakes 3 [times] daily". An email from the prescribing practitioner dated 12/12/22 states "continue TID boost shakes."

The resident's November 2022 through February 5, 2023 MAR were reviewed. There was no documented evidence the resident was receiving TID boost shakes.

The need to follow practitioner orders as prescribed was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

1.Will perform a comprehensive medication and treatment audit for Residents to ensure staff is administering medications and treatments per MD orders. Comprehensive audit to ensure MD orders in need of clarification or clear direction were obtained.

2. Physician orders will be processed through a triple check system to ensure they are entered correctly in the MAR and have final review from nursing to ensure appropriate directions for staff to follow are in place and that there are no duplicate or conflicting orders. Medication delivery system will be followed by Med Techs to ensure medications are being given and treatments are carried out per MD orders and parameters for follow up or notifying MD are being followed. A Nursing check is being added to the MAR order approval process to ensure accuracy.

3. The plan will be evaluated daily when processing new orders in the triple check system, weekly with MAR audits as well as random audits to ensure staff competency.

4. Nurse or designee will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to a medication or treatment order, for 1 of 1 sampled resident (#4) with multiple medication refusals. Findings include, but are not limited to:

Resident 4 was admitted to the facility in July 2019 with diagnoses including Alzheimer's disease and morbid obesity.

Review of Resident 4's clinical records, physician orders and MAR dated 01/01/23 through 02/06/23 identified Resident 4 refused the following ordered medications and/or treatments.

* Estradiol cream (an estrogen steroid hormone) was refused seven times;

* Trazadone (an antidepressant medication) was refused two times; and

* Weekly weights were refused four times.

There was no documented evidence the facility notified the physician of Resident 4's refusals.

The need to ensure the physician was notified when a resident refused consent to a medication or treatment order was reviewed with Staff 1 (Administrator) and Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/223. They acknowledged the findings, and no further documentation was provided.

1. Will ask Physician to update the medication order to better reflect administration instructions.

MedTech will  refusal faxes for each refusal to PCP until further clarifaction is received from PCP regarding the frequency of notification requested.

2. Will inservice staff regarding notifying providers of medication and treatment refusals. By adding to the Phycian Orders request for information as to how often they would like to be notified of medication and/or treament refusals.

3. Will be reviewed on a daily basis with review of medications refused or not given to ensure proper notification to the community RN and the Physician. MedTech to utilize end of shift dashboard to ensure medications are done and reported accurately.

4. Administrator, Nurse or trained designee will be responsible to ensure the corrections are completed and monitored.

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

Resident 3 was admitted in January 2022 with diagnoses including dementia.

Resident 3's 01/01/23 through 02/06/23 MARs were reviewed and revealed the following:

The MAR included Haloperidol (for behaviors) 2 mg/ml solution. Give 0.3 to 0.5 ml (0.6-1 mg) every four hours as needed for agitation, hallucinations, delirium, nausea and vomiting. The following were identified:

*There were no parameters/clear instruction for staff for what dosage to administer; and

* Haloperidol was administered on four occasions in January, and the MAR lacked documentation of the dose administered.

The need to ensure MARs were accurate, included clear parameters and instruction to staff for medication administration was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

1. Will conduct a comprehensive MAR review to ensure MAR is reflective of most recent Physician Order, reviewed for errors in documentation, administration, instruction and parameters and make corrections to be immediately rectified.

2. Will inservice community staff performing daily MAR audit to ensure they understand the regulation and policy regarding missed meds. Proper documentation, transcription of medications, possible duplicate medications and required components will be reviewed during the triple check system and final nursing review.

3. Will be reviewed daily, weekly and monthly basis with triple check, MAR audits, Nursing check off and monthly continuous quailty improvement program.

4. Administrator, Nurse or trained designee will be responsible to ensure the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters for a PRN psychoactive medication, for 2 of 3 sampled residents (#s 1 and 3) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in January 2022 with diagnoses including dementia.

The service plan dated 11/28/22 indicated Resident 3 was moderately forgetful, had occasional difficulty making needs known, word finding difficulty and required staff to offer frequent orientation to person, place and time.

Review of the resident's 01/01/23 through 02/06/23 MARs and progress notes and current physician orders showed the following:

Haloperidol oral solution 2 mg/ml, take 0.6-1.0 mg every four hours PRN for agitation, delirium, hallucinations, vomiting or nausea.

The haloperidol was administered on four occasions between 01/01/23 and 02/06/23.

The MAR did not contain resident-specific parameters describing how the resident expressed  agitation, delirium or hallucinations.

The need to ensure resident-specific information was provided on how the resident expressed agitation, delirium and hallucinations was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. The staff acknowledged the findings.

On 02/08/23, Staff 4 indicated hospice had been notified to re-evaluate the need for the medication and instructions on the MAR were provided to staff not to administer the mediation without RN consultation.

2. Resident 1 was admitted to the facility in June 2018 with diagnoses including dementia, anxiety, and major depressive disorder.

Review of Resident 1's 01/01/23 through 02/06/23 MAR and current physician orders showed the following:

* Lorazepam 0.5 mg tab give 1 tablet by mouth every 4 hours as needed for anxiety, shortness of breath, or dangerous agitation; and

* Olanzapine 2.5 mg tab take 1 tablet by mouth every 6 hours as needed for agitation.

There were no specific reasons for use documented on the MAR which described how Resident 1 exhibited "anxiety" or "agitation", or resident-specific parameters regarding order of use.

In an interview with Staff 17 (MT) on 02/09/23 she stated, "I would probably give her the lorazepam if she was crying or had increased pacing. I don't know when I'd give her the olanzapine."

The need to ensure there were specific reasons for use and resident-specific parameters for PRN psychotropic medications was reviewed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) on 02/08/23. They acknowledged the deficiencies.

1. Will conduct a comprehensive MAR audit to ensure PRN "as needed" psychoactive medications require documentation within the MAR of at least 3 resident specific non-drug interventions attempted and ineffectivness prior to admininstration of medication, including psychoactive medications for hospice Residents who are not actively transitioning or has a physician order stating otherwise. Interventions will be included in the Service plan,  

2. Will ensure the triple check system is performed on each medication order with a final aproval from nursing. Interventions will be service planned for specifity and paramters to use individually for each resident. Trained staff will complete daily, weekly and monthly audits to ensure compliance.

3. Will be reviewed daily, weekly and monthly basis with triple check, MAR audits, nursing review and monthly continuous quailty improvement program.

4. The Nurse or trained designee will be responsible to ensure the corrections are completed and monitored.

Based on observation, interview and record review, it was determined the facility failed to provide a sufficient number of direct care staff to meet the 24 hour scheduled and unscheduled needs of residents to include a minimum of two direct care staff who were scheduled and available at all times when a resident required the assistance of two direct care staff for care needs. Findings include, but are not limited to:

The facility was home to 37 residents at the time of the re-licensure survey. During the acuity interview on 02/06/23, the facility identified multiple residents with high ADL care needs, three of which required two direct care staff to assist with transfers/mobility and ADL care.

During the re-licensure survey a fourth resident, Resident 3, was observed to require two staff to assist with transfers.

The facility's posted staffing plan was confirmed with Staff 1 (Administrator) on 02/07/23. The posted staffing plan showed:

* Day shift: one MT and three CGs;

* Swing shift: one MT and three CGs; and

* Night shift: one MT and one CG.

Review of the facility's staffing schedules dated 01/01/23 through 02/06/23 revealed there were five occasions when one direct care staff was scheduled to work the night shift in both the memory care facility (MC1) and the assisted living facility located on the same campus.

Interviews with staff revealed the following:

During an interview on 02/07/23, Staff 12 (MT) stated she occasionally goes to the other memory care facility (MC2) located on the campus to "help out for a few minutes."

During a phone interview on 02/08/23, Staff 16 (CG) stated there was, frequently, only one direct care staff member on the floor of the memory care (MC1) for at least part of the night shift.

During an interview on 02/09/23, Staff 1 (Administrator) stated she was not aware the facility was not allowed to share staff with the other two, separately licensed, buildings located on the facility's property. Staff 1 acknowledged there were times on the night shift where only one direct care staff was present in the memory care (MC1) facility.

The need to ensure the facility provided a sufficient number of direct care staff to meet the 24 hour scheduled and unscheduled needs of residents to include a minimum of two direct care staff who were scheduled and available at all times when a resident required the assistance of two direct care staff, was discussed with Staff 1 and Staff 2 (Executive Director) on 02/09/23. They acknowledged the findings and modified the staffing schedule to ensure two direct care staff were scheduled and available at all times.

1. No staff will be shared between units. Community uses staffing agency when staff is not available to cover shift. MCD will assist in staff coverage as needed.

2. ABST is used and submitted biweekly to state to reflect staffing levels are being met.

3. Daily, weekly and monthly by MCD or designee to run ABST report and ensure services are being met.

4. Administrator, designee to monitor and adjust staffing levels as needed.

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

Fire drill records for the previous six months were requested.

Review of the documentation provided revealed:

* Fire drills were not conducted every other month;

* Fire drill records did not include location of simulated fire origin; and

* Staff did not evacuate or relocate residents during fire drills; therefore, the facility's fire drill documentation did not include information on escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, and number of occupants evacuated.

The requirements regarding fire drills were discussed with Staff 1 (Administrator) and Staff 21 (Maintenance Director) on 02/07/23 at 10:50 am, and with Staff 2 (Executive Director) on 02/08/23 at 08:50 am. They acknowledged the findings. No further information was provided.

1.Will complete documentation for fire and life safety drills to include date and time of day, location of simulated fire origin, escape route used, any problems encountered and comments related to resident who resisted or failed to participate in the drills, evacuation time period needed, staff members on duty and participating and number of occupants evacuated.

2. Will ensure that proper documentation is obtained for each fire and life safety drill.

3. Will be reviewed monthly to ensure needed items are documented for each drill.

4. Administrator and Maintenance Director will be responsible to ensure the corrections are completed and monitored.   

Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit, and exterior pathways were maintained in good repair. Findings include, but are not limited to:

During a tour of the MCC on 02/06/23 at 10:40 am the following was identified:

* Cleaning materials were observed to be in a cabinet under the sink in the kitchenette area that was part of the dining hall. The cabinet under the sink was not locked and secured. The half-door to the kitchenette was found to be unlocked, allowing residents full access to the kitchenette and the cleaning materials; and

* The pathways of the interior courtyard and fenced patio areas contained drop-offs, up to approximately two and one-half inches in depth in the following areas:

a. from the concrete surface to adjacent planting beds, in the patio area, and;

b. from the concrete pathway to adjacent decorative tiles, in the interior courtyard.

The drop-offs created a potential fall hazard for residents who used the courtyard.

The drop-offs and unlocked cleaning materials were shown to and discussed with Staff 1 (Administrator) and Staff 21 (Maintenance Director) on 02/07/23 at 10:50 am, and with Staff 2 (Executive Director) on 02/08/23 at 08:50 am. They acknowledged the findings. No further information was provided.

1. The chemicals held in kitchen area of the unit will be locked in closet when not in use and kitchen entrance half door to be locked when staff is not present in kitchen. Cabinet lock to be added to safely lock chemicals attached to dish sanitizer. Pathways of interior courtyard will have pea gravel raised to be level to concrete path for no drop off areas.

2. Maintenance to include courtyard to daily walkthrough. Staff to report any changes to level immediately to prevent fall hazards. Task list for kitchen area will include tasks to check for any dangerous chemicals to be safely behind lock and key, staff to lock kitchen half door when staff exit kitchen area.

3. Maintenance team to check courtyard weekly and staff to check daily for pathway areas needing repaired. staff to make sure locks are locked daily and throughout the day.

4. Maintenance team, MCD, MedTech, Dietary Server and staff will monitor and report findings.   

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

During a tour of the MCC on 02/06/23 at 10:40 am the following was identified:

a. Hallways and Resident Rooms:

* Multiple windows in hallways and resident rooms were observed with a build up of dirt on the window sills and the bottoms of the window frames;

* A large, red stain on the carpet in the activity room;

* Multiple ceiling tiles with water damage and stains above the nursing station;

* Gaps between ceiling tiles and support column in nursing station area;

* Gap between nursing station countertop and base;

* Large chip was broken off from countertop base;

* Half-door to nursing station with multiple gouges exposing unfinished wood;

* Light fixture cover in hallway across from Room 126 had water stains inside cover;

* Hole in ceiling tile in hallway across from Room 117;

* Exposed and damaged drywall at toilet paper holder in Room 115;  

* Grab bar on wall in Room 115 was attached to unfinished plywood;

* Torn baseboard molding in Room 125;

* Approximately three-inch diameter hole in wall in Room 125;

* Damaged plate cover on electrical outlet in Room 125, exposing outlet wiring;

* Standing water in bathroom sink in Room 125;

* Odor of urine throughout Room 125 and Room 127;  

* Stained shower curtain in bathroom of Room 125; and

* Missing ceiling light fixture in Room 127.

b. Kitchenette and Dining Hall:

* Multiple ceiling tiles with water damage and stains;

* Baseboard under kitchenette sink was missing, exposing insulation and floorboards under sink cabinet;

* Baseboard under bottom drawer cabinet next to sanitizing machine was missing, exposing floorboard; and

* Cracked light fixture cover with dead bugs inside.

c. Laundry Room:

* Wall vent grate was covered with dust;

* Linoleum flooring torn and missing around floor drain and base of commercial washing machine;

* Floor behind commercial washing machine dirty, rusty and covered with hard water deposits and debris;

* Air conditioning unit on wall next to residential washing machine was attached to unfinished plywood;

* Main door to laundry room was missing molding around door frame on inside of laundry room; and

* Top surface of commercial dryer was covered with a thick layer of dust.

d. Building Exterior:

* Wood framing on walls of fenced patio and interior courtyard was damaged and rotting.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) and Staff 21 (Maintenance Director) on 02/07/23, and with Staff 2 (Executive Director) on 02/08/23. They acknowledged the findings. No further information was provided.

1. Maintenance replaced, repaired ceiling tiles, holes in walls, electrical face plate, touch up paint prior to Surveyors departure. Bids will be obtained for flooring replacement and any other repairs not able to be completed or out of scope of practice of the Maintenance Director.

2. Maintenance team to conduct weekly walk through of community and add ensure evironmental needs are placed in TELS work orders for follow up.

3. Maintenance team to walk through weekly, Direct care team instructed to report any environmental concerns tiemly to Concierge to input into Tels for Maintenance Team.

4. Maintenance Director, Administrator and designee.

Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and a hand wash sink. Findings include, but are not limited to:

During a tour of the MCC laundry room on 02/07/23 at 1:00 pm it was observed there was only one standard utility sink in the laundry room.

In an interview with Staff 20 (Laundry Aid), she stated soiled linens were brought to the MCC laundry room, rinsed in the utility sink and then washed separately in the washing machine. Staff 20 (Laundry Aid) indicated that the utility sink was also used for hand washing.

The need to install a flushing rim clinical sink and have a separate hand wash sink was reviewed with Staff 2 (Executive Director) on 02/08/23. She acknowledged the findings. No further information was provided.

1. Housekeeping supervisor to conduct daily inspections. Maintenance Director is collecting bids regarding Sink installation, flooring replacement, Eye wash station.

2. Maintenance Director to oversee that Houskeeping Supervisor is turning in daily reports and concerns are being entered into TELS.

3. Maintenance Director to oversee weekly and address outstanding concerns.

4. Maintenance Director,  Administrator and Housekeeping supervisor.  

Based on observation and interview, it was determined the facility failed to provide exit door alarms or other acceptable systems for security purposes and to alert staff when residents exit the MCC. Findings include, but are not limited to:

The interior courtyard of the MCC was toured on 02/06/23 at 10:40 am. One exit door leading from an interior hallway to the interior courtyard was observed without a functioning alarm system that alerted staff when a resident exited the building.

In an interview with Staff 21 (Maintenance Director) during a tour on 02/07/23 at 10:50 am, he stated that the alarm box had been removed to replace the battery.

The need to ensure exit door alarms or other acceptable systems for security purposes to alert staff when residents exit the MCC was discussed with Staff 1 (Administrator) and Staff 21 (Maintenance Director) on 02/07/23 at 10:50 am, and with Staff 2 (Executive Director) on 02/08/23 at 08:50 am. They acknowledged the findings. No further information was provided.

1. Door alarm battery was replaced prior to survey exit.

2. Door alarms to be monitored on walk through of community by Maintenance Team and reported by direct care staff.

3.During weekly Maintenance Team walk through and as needed by direct care staff.

4. Maintenance Director, Maintenance Team and Direct Care Team.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the MCC. Findings include, but are not limited to:

The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.

During the re-licensure survey, conducted 02/06/23 through 02/09/23, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in the report.

1. Citations were reviewed with Administrator and training was completed regarding the Abuse and Neglect policy and procedure.

2. Administrator or designee wil look over incidents and utilize the Abuse tree to decide if reportable.

3. Daily reviews of incident reports to be made by adminstrator or designee to determine if it is reportable.

4. Administrator or designee will monitor.

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 360, C 420, C 510, C 513, C 530 and C 555.

1. Please refer to C231, C360, C420, C510,C513,C530, C555

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 8 and 13) completed all required pre-service orientation or dementia training prior to beginning job duties. Findings include, but are not limited to:

Staff training records were reviewed on 02/08/23 and 02/09/23. Staff 7 (CG) was hired 10/13/22, Staff 8 (CG) was hired 11/07/22, and Staff 13 (Dietician Aide) was hired 07/22/22. The following were identified:

a. There was no documented evidence Staff 7, Staff 8, and Staff 13 completed the required Infectious Disease Prevention training.

b. There was no documented evidence Staff 8 completed the required pre-service dementia training in:

* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

The need to ensure newly hired staff completed orientation and pre-service dementia training before independently providing personal care or other services was reviewed with Staff 2 (Executive Director) and Staff 5 (Business Office Manager) on 02/08/23 and 02/09/23. They acknowledged the findings. No further information was provided.

1. Preservice Dementia training is completed during orientation. OAR 411-057-155

2. Preservice dementia training will be done prior to staff working with residents. Relias modules will be completed.

3.Business Office to routinely audit files to ensure required training is completed.

4. Administrator, Business Office Manager to oversee and enter required documentation stating training has been completed.

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

Refer to C 260, C 270, C 280, C 290, C 303, C 305, C 310 and C 330.

1. Please refer to C260, C270, C280, C290, C303, C 305, C310 and C330

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in service plans for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 3's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN), and Staff 4 (RN) on 02/08/23. They acknowledged the findings.

1. Resident specific nutrition and hydration plans will be individualized and resident service plans updated.

2. Service plan assessments by nursing and Administrator, communication with direct care staff, direct observation will be implemented in service plan.

3. On admission, after 30 days, quarterly and when there is a Change of Condition.

4. Admininstrator or designee is responsible for updating nursing recommendations and succesful interventions from TSP.  

Based on observation, interview and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 1, 2, 3, and 4's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following:

* Current abilities and skills;

* Emotional/social needs and patterns;

* Adaptations needed to participate;

* Identification of activities for behavioral interventions; and

* There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities.

Observations of the residents from 02/06/23 through 02/09/23 showed multiple residents wandering the halls, residents seated in the TV area for extended periods, or residents remaining in their rooms unengaged with no activities.

Interviews with caregivers on 02/06/23 and 02/07/23 indicated the activity director was not regularly on the unit, and it was the caregivers who were initiating group activities in between their caregiving and medication duties.

The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN) during interviews on 02/08/23 and 02/09/23. They acknowledged the findings.

1. Residents will have an activity evaluation conducted at move in. And updated as needed to reflect likes and wants specific to resident.

2. Activity Support will meet with newly admitted residents and family to obtain information on likes, interest, hobbies and previous activities engaged in.

3. On admission, 30 days, quarterly.

4. Administrator designee, Activity support persons to be trained to accuratley collect data and report data.  

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 4 sampled residents (#s 2 and 3) with documented behaviors. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in November 2022 with diagnoses including dementia.

Resident 2's record documented behaviors including exit seeking, refusal of care, resident to resident altercations, aggression and combativeness.

The resident's service plan, dated 01/27/23, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 02/09/23 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 4 (RN). They acknowledged the findings.

2. Resident 3 was admitted to the facility in January 2022 with diagnoses including dementia.

Resident 3's record documented behavior to include agitation, delirium and hallucinations.

The resident's service plan, dated 11/28/22, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 02/09/23 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator), Staff 2 (Executive Director), Staff 3 (LPN) and Staff 4 (RN). They acknowledged the findings.

1. Resident service plans will updated with resident specific interventions regarding individual behaviors and how they effect others in the community.

2. Residents with harmful behaviors to themselves or others will be evaluated by an outside consultant and/or an acute setting. Any interventions recommended by behavioral consult will be implemented in service plan if appropriate.  

3. At least quarterly and any time resident exhibits new behaviors as well as when seen by outside consultant. Up to and including acute care.

4. Adminstrator, DHW/RN and LPN