Print Inspection: 68Q4

The findings of the re-licensure survey conducted 06/21/22 through 06/23/22 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 re-visit to the re-licensure survey of 06/23/22, conducted 09/13/22 through 09/14/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

2. Two sampled residents who were interviewed during the survey reported not liking the food. One of the residents went on to state, "It all tastes pre-made. There isn't a lot of fresh fruits and vegetables. [The facility] has gone with the cheapest supplier and I can taste it."

A test tray was requested from Staff 5 (Dietary Manager) on 06/22/22 at 11:35 am.

The test tray was served to the surveyor team at 11:57 am. The meal was served uncovered and consisted of a soft shelled beef taco, corn with tomatoes and peppers, Spanish rice and banana pudding.

The ground beef used in the soft shelled taco did not taste seasoned and the beef had overcooked pieces which made it dry, crunchy and chewy.

The Spanish rice did not taste seasoned and was overcooked to a mechanical soft like texture.

The need to ensure the meals served were palatable was discussed with Staff 1 (Administrator), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure nutritious and palatable meals and snacks were provided in accordance with the United States Department of Agriculture (USDA) guidelines, and facility kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

1. The kitchen was toured on 06/21/22 with Staff 5 (Dietary Manager). The following was observed to be in need of cleaning or repair:

* The tile flooring underneath the warewashing machine had deep grooves and gouges;

* The tile baseboard underneath the warewashing machine had fallen off the wall and was lying on the floor;

* The floor tile had black matter build up;

* The tiles along food prep and stove were cracked;

* The ceiling tile above the hood range had a gouge exposing raw material;

* The green exit door in kitchen had scuffs and rust colored spots;

* The cabinets in coffee bar had scuffs and scrapes across the front; and

* The ceiling tiles in dry storage above shelves had black scuff marks.

The need to ensure the kitchen was clean and in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.

1. Kitchen cleaning and damage repair to noted area of tile, kitchen door, coffee bar cabinet and ceiling tiles above hood and storage will take place.

Meals will be prepared using the new recipes and menu guides, and will be sampled for quality control to ensure residents are served palatable meals

2. Dietary staff will use the work order system for repairs, cleaning schedules and weekly walk throughs to ensure ongoing compliance.

ED/designee to sample meals to ensure quality of meals, and resident feedack to be obtained via weekly dining comment cards and monthly Dining Committee for the previous 3 months.

3. ED and Dietary Manager to conduct weekly kitchen walk throughs to ensure compliance

ED/designee to sample 2 meals weekly and provide feedback to dietary manager. Dining Committee shall meet monthly ongoing as a part of the QA process.

4. ED, RDO, Dietary Manager, Maintenance

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

1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.

Review of the current service plan, dated 06/12/22, observations of the resident and interviews with the resident and caregiving staff indicated the service plan lacked the following information:

* Clear instruction to staff regarding compression stocking use, including use of lotion and treatments; and

* Instruction to staff regarding care needs after tooth extraction.

2. Resident 4 was admitted to the facility in 04/2015 with diagnoses including rheumatoid arthritis.

Review of the current service plan, dated 03/08/22, indicated handwritten changes regarding side rail use and instructions to staff were not dated and initialed.

The need to ensure service plans were reflective of the residents' status, updated, and provided clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

1. Resident #2 and #4 SP updated to reflect missing resident specific items and SP conference to be held.  

2. ED to conduct inservice with staff on the proper service planning process and to review OAR with the service planning team. Evaluation tool in PCC was updated to cover OAR areas and to feed directly to the service plan

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

4. RN and ED or designee are responsible

2. Resident 3 was admitted to the facility in 02/2019 with diagnosis including diabetes and cognitive impairment.

The resident's medical record was reviewed and interviews were conducted. The following lacked documented evidence of monitoring through resolution:

a. On 06/02/22, a progress note stated Resident 3 had returned from the hospital after sustaining a fall out of bed that resulted in rib fractures and a pelvic fracture. The resident did not need surgical interventions for the fractures.

Per the facility's "alert charting and audit tool", a return admission from the hospital would constitute 72 hours of monitoring. The facility lacked documented evidence the return from the hospital and Resident 3's fractures had been monitored through resolution.

b. On 06/07/22, the resident had an increase in Hydrocodone (for pain). There was no documented evidence the change in medication had been monitored through resolution.

The need to ensure residents' short term changes of condition had documentation of weekly monitoring through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine what actions or interventions were needed for short term changes of condition, communicate those changes to staff on each shift and failed to monitor changes through resolution for 2 of 3 sampled residents (#s 2 and 3) who were reviewed with changes of condition.  Findings include, but are not limited to:  

1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including stroke and major depressive disorder.

Resident 2's medical record was reviewed. Multiple changes of condition were identified with the following deficiencies:

a. No actions or intervention developed, no communication to staff on each shift or evidence of monitoring for the following changes of condition:

* Tooth extraction; and

* Urinary tract infection.

b. Lack of weekly monitoring for:

* Left ankle wounds;

* Wound under left knee;

* Red rash to bilateral legs; and

* Red rash/burn to top of both hands.

c. Lack of monitoring through resolution for:

* New medication on alert charting 04/01/22; and

* Skin abrasion to forehead.

The need to ensure all changes of condition were evaluated, had interventions developed, were communicated to staff on each shift and monitored weekly for effectiveness through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

1. Resident #2 and #3- Change of Condition were reviewed and documentation completed reflecting the changes and SP  to be updated as needed.

2. 24 hour process will be reviewed and retraining as needed will be provided to Med Techs and RN to ensure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED will review in clinical meeting and address/document accordingly.

3. Review of 24 hour binder and audit tool will be conducted M-F during clinical meetings. Monthly QA Audit of the 24 Hour process will be conducted ongoing as a part of conitnued compliance.

4. ED and RN or designee are responsible

Based on interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers for 1 of 2 sampled residents (#2) who received services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder.

Review of outside provider communications in the resident's record indicated the following recommendations were made:

* 03/31/22: "Adaptive handle for motorized chair so s/he can reach lever to rotate chair for transfers," recommended by HHPT on Health Professional Communication form;

* 05/09/22: "Edema can be treated with ...restriction of dietary sodium intake and diuretics," on Patient Handout from dermatology Nurse Practitioner;

* 06/02/22: "Monitor bilateral circulation," recommended by HHRN on Health Professional Communication form; and

* 06/08/22: "Please remove Unna boot in 4 days - on 06/12/22 and apply Triamcinolone cream thereafter 1 time a day under compression socks," from dermatology Nurse Practitioner handwritten note on day of service.

There was no documented evidence these recommendations were communicated to staff or implemented as appropriate.

The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

1. Resident #2 home health notes have been reviewed and documentation completed reflecting outside provider reccomendations. Staff have been made aware of changes, via tsp and service plan to be updated as needed. Resident # 2 was reassessed with no negative outcome.

2. 24hr process to be reviewed with staff to ensure communication regarding New outside provider notes or reccomendations. RN and ED will review any outside provider notes M-F in clinical meetings.

3. Review of outside provider binder, including audit, will be conducted Monday through Friday during clinical meeting ongoing.

4. RN and ED responsible

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

Resident 2's signed physician orders and 06/01/2022 through 06/21/22 MAR/TAR were reviewed. The following orders were not carried out as prescribed:

* Triamcinolone cream - one time a day under compression socks was ordered on 06/08/22. The facility failed to implement the new order, continuing to administer Triamcinolone cream bid;

* Mupirocin 2% ointment -  "apply to wounds on legs every day until resolved" was ordered on 04/29/22. Leg wounds were resolved 05/09/22 per progress note and Staff 2 (RN) interview. The 06/01/22 through 06/21/22 TAR indicated Mupirocin was still being administered; and

* Six treatments lacked documented evidence of administration on the 06/01/22 through 06/21/22 TAR.

The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator), Staff 2, Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

1. Comprehensive physican's order review was  conducted for resident #2, in addition 10 residents physican orders will be reviewed for accuracy by date of compliance  

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

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

Bring any findings to internal QA meeting monthly

4. ED and RN responsible  

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to medication and treatment orders for 1 of 1 sampled resident (#2) who had documented treatment refusals. Findings include, but are not limited to:

Resident 2's 06/01/22 through 06/21/22 MAR/TAR was reviewed. The record showed 10 instances of treatment refusal.

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

The need to ensure the facility notified physicians of medication and treatment refusals was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

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

2. Inservice Med Techs on proper notification of refused medications.

3. Lead Med Tech/RN/ED or designee to check for refused medications M-F and ensure proper notifications were made x4 weeks and then spot check 2 times per month as part of internal QA process. Bring findings to monthly internal QA meetings

4. ED, RN and Lead Med Tech or designee responsible

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication specific instructions including significant side effects and when to call the prescriber or nurse and failed to ensure resident-specific parameters for PRN medications for 2 of 3 sampled residents (#s 2 and 3) whose medications were reviewed. Findings include, but are not limited to:  

1. Resident 3 was admitted to the facility in 02/2019 with diagnoses including diabetes and cognitive impairment. The resident's 06/01/22 through 06/21/22 MAR and TAR was reviewed and revealed the following:

* Two PRN bowel medications to treat constipation lacked parameters on when to initiate treatment and what medication to administer first; and

* Scheduled and PRN blood glucose monitoring was lacking resident specific instructions on when to notify the prescriber or nurse relating to high blood sugar readings.

There was an entry on Resident 3's TAR to notify the prescriber monthly of any medication refusals. There was an entry on 06/13/22 which prompted to "Other / See Nurse Notes." There was no documented evidence of a corresponding nurse note.

The need to ensure residents' MARs and TARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations) and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 05/2021 with diagnoses including history of stroke and major depressive disorder. The resident's 06/01/22 through 06/21/22 MAR/TAR was reviewed and the following deficiencies were identified.

a. The medication record contained no medication specific instructions, if applicable, including significant side effects. Resident 2 was on alert charting beginning 04/30/22 for new medications, including Doxycycline. A progress note dated 05/13/22 stated "resident is on alert for red rash/burn to the top of both hands, right hand appears to be swollen. Resident is complaining of pain and states that it burns. Resident believes that the Doxycycline is what's causing the redness to [resident's] hands."

b. There were no parameters for two PRN pain medications: acetaminophen and hydrocodone/APAP; and

c. There were 36 entries on TAR that indicated either "Hold/See Nurse Notes" or "Other/See Nurse Notes." There was no documented evidence of corresponding nurse notes.

The need to ensure MARs/TARs were complete and accurate was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Regional Director of Operations), and Staff 4 (Regional Nurse Consultant) on 06/23/22. They acknowledged the findings.

1 - Resident #3 medications reviewed to include specific instructions for staff. Resident #2 medications were reviewed and corrected to address parameters. All resident orders to be reviewed and ensure resident specific instructions and/or parameters are in place

2 - Training to be provided to health services team regarding order confirmation, clarification of orders and proper parameters  

3 - Audit orders for parameters and instructions as new orders are received during the clinical meeting, and 2 at random monthly as a part of QA process

4 - Lead Med Tech, RN, ED or designee responsible  

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 3 of 3 newly-hired direct care staff (#s 9, 10 and 14). Findings include, but are not limited to:

The facility's training records were reviewed on 06/22/22 and 6/23/22.

Staff 9 (CG), hired 12/09/21, Staff 10 (CG), hired 01/18/22, and Staff 14 (CG), hired 04/05/22, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.

The need to ensure all newly hired, direct care staff had the required pre-service dementia training prior to providing care to residents was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/23/22. They acknowledged the findings.

1. All employee files to be audited for the presence of all required preservice dementia training.

2. New employee onboarding process to be reviewed/ completed with ED to ensure that new hire checklist is completed and accurate for all new employees with documented evidence.

3. Employee Training Grid to be used to track all employee pre-service dementia training. ED to audit 3 files/month for accuracy and completeness.

Audit findings to be brought to internal QA meeting

4. ED, RDO responsible

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instructions to staff was provided on alternate months and failed to ensure written fire drill records included all required components. Findings include, but are not limited to:

On 06/22/22 fire and life safety records for 12/21/2021 through 05/15/2022 were reviewed.

1. Fire and life safety training was not consistently being provided to staff on alternating months of fire drills.  

2. The facility was not consistently evacuating or relocating residents during fire drills. Fire drill documentation was lacking or incomplete regarding:

* Escape route used;

* Evacuation time-period required;

* Number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The need to ensure staff received all required fire and life safety training and fire drills included all required components was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.

1. Fire drill form with appropriate Fire Life Safety requirements to be reviewed with maintenance director with immediate corrections and will be in compliance by compliance date. Documented evacuations that include residents, as well as alternating saftey training will be adequately documented with clear instructions on routes and procedures.

2. Fire drills, evacuations and staff safety training to be conducted on company standardized forms which address all needed requirements per OAR to include resident/ staff training, involvment and adequate documentation with proper filing.

3. Fire drills/training to be reviewed during internal QA meeting monthly to ensure compliance.

4. ED responsible

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:

On 06/22/22 at 10:48 am, Staff 6 (Maintenance) confirmed the facility had not been providing annual fire and life safety training to residents.

The need to ensure fire and life safety instruction was provided to residents at least annually was reviewed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.

1.Facilty has implemented and scheduled annual fire evacuation training that will be conducted before 8/22/22.

2. All residents to be trained on fire safety, fire roles and responsibities, and evacuation upon move in and annually per the new schedule.

3. Fire drills/training to be reviewed during internal QA meeting to ensure compliance monthly

4. ED responsible  

Based on observation and interview, it was determined the facility failed to ensure the exterior pathways and accesses to the facility common use areas, entrance and exit ways were maintained in good repair. Findings include, but are not limited to:

The facility grounds and sidewalks were observed on 06/21/22 and the following was identified:

* Outside the facility entrance the green wicker chair left arm rest was fraying;

* The enclosed eaves to the left of the front door had a hole;

* Drop-offs at approximately three to seven inches in height along sidewalks; and

* The walkway next to mechanical room had hole measuring approximately 20 inches by 30 inches and was deep enough that the surveyor was unable to visualize the bottom. The hole was covered with wood creating an uneven surface.

The drop-offs and hole created potential tripping hazards for residents.

The need to ensure the exterior pathways and accesses to the facility common use areas was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.

1. Wicker chair was removed and hole in eave and sidewalk drop offs in back of communiity, have been scheduled for repair. Project completion estimated for 08/22/22. While awaiting completetion, caution tape has been put into place to prevent resident access.  

2. All staff to be inserviced to the workorder process for repairs and maintenance.  

3. ED and Maintenance Director to conduct weekly walk throughs, as well as internal QA meetings to review building maintenance audits. RDO to complete quarterly building walk through  

4. RDO, ED, Maintenance Director responsible

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

The interior and exterior of the building were toured on 06/21/22. The following areas needed cleaning or repair:

a. Facility Wide

* Multiple resident rooms, facility doors and door frames had scuffs, scratches and gouges;

* The carpet throughout the facility had stains; and

* Multiple walls throughout the facility had gouges and scuffs.

b. First Floor

* The front desks left corner was chipped exposing wood underneath;

* The elevator panels had gouges and scuff marks; and

* The carpet baseboard was fraying where it attached to wood baseboard in dining room next to the salon and staff lounge.

c. Housekeeping / Hopper Room

* The corner had a gouge in wall exposing material underneath;  

* The hopper had debris around the rim and sides; and

* The power outlet plate was broken next to the door.

d. Laundry Room

* The vinyl tiles were broken and missing underneath the left dryer exposing wood;

* The ceiling tiles had rust color stains and one was missing;

* The cabinets had scuff marks along the front; and

* The chair seat on the brown chair had white and black stains.

e. Dining Room

* The pillar had gouges and scuff marks;

* The screen was bent in the left window; and

* The vinyl flooring was cracked and did not connect around the gold floor cleanout cover creating a hole.

f. Ice Cream Bar

* The grout to tile countertop had black debris build up; and

* The baseboards had black debris on the top.  

g. Second Floor

* The carpet was fraying at the second-floor threshold into the elevator;

* The black tables in the Activity Room had gouges exposing wood; and

* The carpet baseboard had white debris on it in the Activity Room.

The areas needing cleaning and repair were shown to and discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22 at 1:05 pm. They acknowledged the findings.

1. Interior and Exterior deficiencies noted in the 2567 will be reviewed and repaired.

2. All staff to be trained on utilizing work order system to ensure needed repairs are addressed timely.

3. ED and Maintenance Director to conduct weekly walk throughs, as well as monthly QA meeting audits. RDO to complete quarterly communitiy walk though to ensure compliance.  

4. RDO, ED and Maintenance Director

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

During an environmental walk-through on 06/21/22, the following was identified:  

Fireplaces were observed turned off during the survey.

* The Surveyor turned on the lobby fireplace via a wall timer at 1:50 pm.  The surveyor measured the front glass covering at 1:54 pm, it measured 212 degrees F with the surveyor's thermometer.

* The Surveyor turned on the Activity Room fireplace via a wall timer at 2:22 pm.  The surveyor measured the front glass covering using the surveyor's thermometer at 2:28 pm, it measured 174 degrees F.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1 (Administrator) and Staff 3 (Regional Director of Operations) on 06/22/22. They acknowledged the findings.

1. Immediate action was taken for the safety of our residents. The fireplaces were turned off and disabled until the new fireplace screens arrived that week.  screens were secured in place.

2. Ongoing checks to ensure the screens are in place and to ensure the residents cannot come in contact with the hot surface.  

3. ED and Maintenance Director to ensure proper placement of safety screens weekly during walk throughs and monthly temps will be conducted.  

4. ED and Maintenance Director are responsible