Print Inspection: 5K5Q

The findings of this Change of Owner re-licensure survey conducted 04/11/22 through 04/13/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 04/13/22, conducted on 07/12/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

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

Resident 1's move-in evaluation, dated 03/28/22, lacked information regarding the following required elements:

* Personality;

* Laundry; and

* Environmental factors.

The move-in evaluation was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

1. Evalutions were changed to include the following: personality, laundry and environmental factor for new move ins. These changes are permanet and will be in place, unless changes are to be made for these specific items upon evaluation renewal. Admin and RCC to review the above stated, in the evaluation.

2. Evaluations in facility system have been changed to include these items, when a new resident moves in, these questions will be answered.

3. Corrections will need to be made, if any, when evaulations are due (30, 60, 90 & 90 days after resident moves in).

4. Admin and RCC will make these changes when evaluations are due.

3. Resident 2 was admitted to the facility in 2021 with diagnoses including a neurogenic bladder. The resident's 01/11/22 through 04/11/22 progress notes were reviewed and revealed the resident experienced the following changes of condition:

* 01/08/22 " ...[Resident's] catheter was pulled out.";

* 01/11/22" ...This resident pulled [his/her] catheter out."; and

* 02/12/22" ...CG notified this MT that this resident's Foley catheter came out."

The facility lacked documented evidence the resident was evaluated to address the reoccurring issue with interventions determined documented, communicated to staff and the condition monitored and noted at least weekly through resolution.

The need to ensure all changes of condition were evaluated with interventions determined, documented, communicated to staff on all shifts and conditions monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 2017 with diagnoses including type 2 diabetes. The resident's 01/11/22 through 04/11/22 progress notes were reviewed and revealed the resident experienced bilateral lower extremity pressures ulcers.

The facility lacked documented evidence they monitored the resident's wounds with progress noted at least weekly through resolution.

The need to ensure all changes of condition were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident, communicate the interventions to staff, ensure interventions were resident-specific and monitor interventions for effectiveness, for 4 of 4 sampled residents (#s 2, 3, 4 and 5) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 8/2017 with diagnoses including Parkinson's.

A review of the resident's clinical records, 01/02/22 through 04/07/22, indicated the following changes of condition:

* 01/08/22 Resident had a fall with abrasion to right knee;

* 01/16/22 Resident was found kneeling on floor next to bed;

* 01/31/22 Resident was found crawling on floor and unable to get up independently;

* 02/17/22 Resident had a new order for chlorehexidine (topical antiseptic);

* 03/06/22 Resident was found kneeling on floor, abrasion to right knee bleeding;

* 03/24/22 Prescription changes to meloxicam (anti-inflammatory), tramadol (pain medication) and eye drops; and

* 03/31/22 Resident slid out of chair in dining room.

There was no documented evidence the facility had evaluated these changes (to determine actions and interventions, provided written instructions to staff, and/or monitored the above documented changes of condition to resolution.  

The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 03/2019 with a diagnosis of rheumatoid arthritis.

A review of the resident's clinical records, 01/06/22 through 04/10/22, revealed the following changes of condition:

* 02/17/22 New antibiotic (for UTI).

There was no documented evidence the facility had provided written instructions to staff, and/or monitored the above documented changes of condition to resolution.  

The need to ensure all changes of conditions were reviewed, resident specific actions and interventions were developed and communicated to staff, and monitored until resolution was updated was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

1. New Alert Charting binder system has been created to better track the conditions of the issues that residents have. ISP (interim service plans) will be written out located in the service plan binders so caregivers to keep track of condition they will look out for.

2. This alert binder will give a consolidated space for Med Techs to write progress notes on resident's condition/monitoring them. Caregivers report to Med Techs and to be added to their progress notes.

3.LPN is onsite for three days of the week, MSN is onsite for one day. Nursing staff is the only ones to determine which alerts will be taken off, and those that need to be monitored longer.

4. LPN and MSN

Based on interview and record review, it was determined the facility failed to ensure signed physician's orders were in place for all medications administered to the residents for 1 of 3 sampled residents (# 4) whose MARs were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2017 with diagnoses including Parkinson's. The resident's 04/01/22 through 04/11/22 MARs and physician's orders were reviewed.  

The following medications had no documented evidence of a physician's order in the resident's medical chart:

* Acetaminophen (for pain);

* Albuterol (for SOB);

* Benzonatate (for cough);

* Bisacodyl (for constipation);

* Docusate Sodium (for constipation);

* Guaifenesin (for cough);

* Loperamide (for loose stool);

* Quetiapine Furmate (for agitation); and

* Salonpas pain patch (for pain).

The need to ensure signed physician's orders were in place for all medications administered was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

1.All residents have complete physician orders in place.

2.Med Techs are go ensure that all physicans orders (including pages) are signed off by physicans.

3.RCC and LPN to reconcile all orders received from faxes and or from doctor appointments in a timely manner.

4. RCC and LPN on onsite days

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a current Residential Care Facility Administrator license. Findings include, but are not limited to:

On 04/11/22, Staff 1 (Administrator) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 revealed her license had expired.

The requirement to have a current Residential Care Facility Administrator was discussed with Staff 1 on 04/13/22. She acknowledged the findings.

1. Admin renewed license and will continue to keep it up to date.

2. Mailing address has been updated, when letter of renewal comes, admin will take action.

3. License will be renewed annually.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 4 and 10) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Facility training records were reviewed on 04/13/22. The following deficiencies were revealed:

1. Staff 4 (CG), hired 12/15/21, lacked documented evidence of the following pre-service orientation topics:

* Fire Safety and emergency procedures; and

* Six hours of approved dementia care training.

2. Staff 10 (CG), hired 09/01/21, lacked documented evidence of the following pre-service orientation topics:

* A written job description;

* Fire Safety and emergency procedures; and

* Six hours of approved dementia care training.

The need to ensure all required pre-service orientation was completed prior to newly hired direct care staff beginning their job responsibilities was reviewed with Staff 1 on 04/13/22. She acknowledged the findings.

1. Facility will assign classes through Oregon Care Partners that will provide a certificate for infection control, abuse and reporting requirements, resident's rights, and dementia training.

2. RCC will collect and file certificates, job description, food handler cards, community fire life safety procedures, and other misc. documents in employee profile/upload to Alis program. This program keeps track of compliance documents for staff.

3. RCC to coorespond with staff monthly to ensure that training is completed.

4. Administrator and RCC.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 4 and 10) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Facility training records were reviewed on 04/13/22. The following deficiencies were revealed:

Staff 4 (CG), hired 12/15/21, and Staff 10 (CG), hired 09/01/21, lacked documented evidence they demonstrated satisfactory performance in any duty they were assigned within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation and reporting changes in condition;

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

* First Aid/abdominal thrust.

The need to ensure newly hired staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/13/22. They acknowledged the findings.

1. Admin and RCC will use caregiver compentency check off for staff within 30 days of hire.

2. Compentency check off for new staff was added to profiles of staff who are able to check off ADLS. Alis program is able to help track this item is completed. 3.RCC or Admin to conduct check off for new hires within 30 days of hired date.

4. RCC and Administrator

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month, document all required components of fire drills and provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:

Fire drill records from 09/2021 through 03/2022 were reviewed on 04/12/22. The facility lacked documented evidence fire drills were conducted every other month and included the following required components:

* Time of day;

* Location of simulated fire origin;

* The escape route used;

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

* Evacuation time period needed; and

* Number of occupants evacuated.

The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.

On 04/13/22, the need to ensure fire drills were conducted every other month, all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (Administrator). She acknowledged the findings.

1. Admin will conduct alarm and unalarm fire drills evey other month in accordance with OAR 411054-00901 a-d.

2. Admin and RCC have scheduled fire drills and safety meetings/classes to education staff on certain days. Reminders for these classes are on the calendar.

3. These will be conducted every other month, starting next month. Staff with be supplied with a handout, and a sign in sheet. Those who are not able to attend will be asked to come on another day and RCC will go through items discussed.

4. Administrator and RCC

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Fire drill records from 09/2021 through 03/2022 were reviewed on 04/12/22. The facility lacked documentation of the following required elements:

* Evidence alternate routes were used during fire drills; and

* Evidence residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Administrator) on 04/13/22. She acknowledged the findings.

1.Admin will ensure upon move in that the resident is given written or verbal instructions on evacuation.  Signed copy of written instructions will be placed in residents chart. Admin will have alarm and unalarm fire drills every other month, and fire and safety in between those months, that will focus on but not limited to: earthquake, bomb threat, shooting, etc. These will be documented by the Admin and the alternate evacuation routes taken.

2. New forms have been created for new move in and are to be signed off by resident if they are able to cognitively follow instructions. Handouts have been created for staff training for fire and life safety topics. After meetings are finished, handouts will be place in binder so staff can look back and view them.

3. Form for new residents to be signed off within 24 hours of move in time. Fire drills and safety meetings to be done every other month.

4.Adminstrator and RCC