Print Inspection: 8V4B

The findings of the re-licensure survey conducted 04/01/24 through 04/04/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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

MCCMemory 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 04/04/24, conducted 09/24/24 through 09/26/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and suspected abuse, and reported to the local SPD (Seniors and People with Disabilities) office when abuse could not be ruled out for 2 of 2 sampled residents (#s 4 and 5). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.   

Interviews with the resident and staff were conducted. Resident 4's 12/21/23 service plan, Temporary Service Plans, progress notes dated 12/14/23 through 03/01/24, and incident investigations were reviewed. The following was identified:

* 01/23/24 - The resident was observed touching another resident of the opposite gender, staff documented the touch "did not seem consensual."

On 04/03/24 survey requested Staff 2 (Assisted Living Director) to report the incident to the SPD office if she was unable to locate the documentation. Staff 2 provided verification she reported the incident that occurred on 01/23/24 to the local SPD office on 04/03/24.  

Although the facility completed an investigation for the 01/23/24 incident, the facility failed to include the following required components:    

* Individuals present;

* Description of the event as reported;

* Response of staff at the time of the event;

* Follow-up action; and

* Administrator's review.

The need to ensure all incidents of abuse or suspected abuse were immediately reported, and investigations included documentation of all required elements, was discussed with Staff 1 (ED), Staff 2, and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

2. Resident 5 was admitted to facility in 11/2023 with diagnoses including Parkinson's disease.

Interviews with staff and review of the resident's 02/29/24 service plan, 01/02/24 through 03/27/24 Temporary Service Plans, progress notes, and incident investigations were reviewed. The following was identified:

On 01/03/24 an incident report indicated Resident 5 was found sleeping on the floor and had an abrasion to his/her right cheek on 01/02/24. "Resident doesn't know what happened" but stated "Assumed [s/he] was intoxicated, fell then fell asleep."

On 01/04/24 the RN completed a follow-up that stated abuse and neglect were ruled out. However, the follow-up action lacked documented evidence to reasonably conclude the falls were not the result of abuse or neglect.

The need to ensure all incidents and injuries of unknown cause contained all required areas of documentation including if abuse could be ruled out, and if not, incidents and injuries of unknown cause were reported to the local SPD office, was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 5's incident was reported to SPD when reporting requirement was made known.

Resident 4's incident report was done and reported to SPD

All staff were inserviced on Abuse Reporting Requirements and the required components and time frame for reporting abuse, suspected abuse, and injuries of unknown cause.

ED, ALD, RN, Med Techs & Caregivers were inserviced on Root Cause Analysis.

System audited by LN or Designee three times weekly for three months by reviewing daily charting and incident reports and investigations.

Any instances of missing APS reports found will be brought to QA monthly for further review.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

On 04/01/24 at 11:57 am, observations of the facility's main kitchen identified the following:

a. Food Storage

* The reach-in and walk-in refrigerators and freezers throughout the kitchen were in need of cleaning in both the interior and exterior surfaces;

* Not all food items were covered or dated (e.g. an uncovered pan of peas was observed on 04/01/24 and on 04/03/24 in the freezer);

* There were three large plastic containers located in the dry food storage area that had sticky matter present with the potential of attracting insects;

* There was dust build up observed on the fans in the walk-in refrigerator; and

* There was debris on the walk-in freezer floor;

b. Food Preparation

* One of the soup warmers was leaking water;

* None of the five gallon ice cream tubs were observed to be covered in the ice cream freezer;

* An area under the water station had a missing vent and was observed to have built up matter and a constant drip;

* The bins in the back of the kitchen that stored flour, panko, sugar, and oatmeal  were observed to have scoops in them; and

* A "powdered sugar" drawer, located in the stainless steel warming table, was observed to have a scoop in it.

c. Sanitation and Equipment

* Staff were unaware of where the testing strips were located for the sanitation buckets;

* The shelving above the ice cream freezer had a dirty, clear, plastic table display cover alongside of the clean ice cream bowls;

* The lower shelving on each side of the ice cream freezer had drips and debris;

* The right door handle located on the ice cream freezer was loose;

* There was a vent directly above the ice cream freezer that was detaching from the ceiling;

* Multiple cutting boards, including the one attached to the steam table, had deep grooves and score marks and were uncleanable;

* The oven, stove, and convection oven were in need of internal and external cleaning including the backsplash behind the equipment;

* The heating elements located above the steam table where food was exposed, was observed to have rusted;  

* The faucet located in the back section of the kitchen at the three compartment sink had a constant drip;

* The meat cutter and stand up mixer were not covered when not in use;

* The guard located in the industrial mixer had dried food debris; and

* There was a wood food prep table with score marks and grooves observed making it an uncleanable surface.

d. Dishwashing Area

* Debris and food matter was observed underneath the dishwashing area;

* Dust on pipes was observed;

* The floor directly under the sink was cracked; and

* The lower shelving where the dish racks were stored was in need of cleaning.

e. Janitor Closet

* The walls, floor, and ceiling of the janitor's closet was observed to have drips, debris, and rust present;

* The flooring was in disrepair and had built-up debris;

* There were stiff, dirty towels located in the sink;

* The paper towel dispenser had built up debris; and

* The bucket used to mop the floors had grayish brown water inside of it during two days of observations.  

f. Throughout the Kitchen

* Multiple doors and door jambs had chipped paint and gouges;

* The door leading from the dining room into the kitchen was in disrepair and had chipped paint and duct tape was observed;  

* Multiple drains throughout the kitchen had brown and black matter in them;

* Multiple walls and sides of the stainless-steel work areas had spills, drips, and debris;  

* Multiple drawers and cabinets located inside of the stainless-steel food prep and storage areas had built up debris and spills;  

* Flooring throughout the kitchen was damaged and had black or brown buildup;  

* None of the garbage containers were observed to have lids;

* Multiple exposed pipes throughout the kitchen had built up dust and debris observed;

* There were multiple drawers and cabinet doors located within the stainless-steel work areas that were in disrepair;

* Upper shelving on multiple stainless-steel work areas had dust, debris, and were sticky to the touch;

* Multiple areas in the ceiling had paint peeling down, trim was peeling away from the adjacent walls, and there were panels observed to be in disrepair;

* Multiple light fixtures had debris both inside and outside and were missing light bulbs;

* Multiple metal carts where food was being stored on trays had debris and splatters;  

* The food warming carts were observed have drips and debris located on both interior and exterior surfaces; and

* The "Team Member" refrigerator was in need of interior and exterior cleaning.

g. Dining Room

* Multiple seats in the chairs were worn, cracked, or missing vinyl;

* Some of the backs of the chairs were loose; and

* Gouges and chipped paint were observed on multiple pillars, baseboards, and walls.

h. Also, although a general sick policy was provided, there was not a sick policy specific to kitchen staff.

The need to ensure the kitchen was clean and in good repair per the Food Sanitation Rules was discussed with Staff 1 (ED) and Staff 6 (Dietary Supervisor) on 04/01/24 and 04/03/24. They acknowledged the findings.

All items cleaned in the Kitchen: Reach in fridge & freezer; Large plastic containers in dry storage; Fans in walk-in refrigerator; Floors in walk-in freezer; Area under the water station; Lower shelving on each side of ice cream freezer; The oven, stove, convection oven and backsplashes; Industrial mixer guard; Debris under the dishwasher; Dust on pipes in dishwashing area; Lower shelving where the dish racks are stored; The Janitor's closet walls, floors, ceiling, and paper towel dispenser; All floor drains; All walls and sides of stainless steel work areas; All drawers and cabinets in the stainless-steel food prep and storage areas; All exposed pipes; All upper shelving on stainless-steel work areas; All light fixtures; All metal carts where food is stored on trays; All food warming carts; Team member refrigerator.

All items repaired in the Kitchen & Dining Room: Soup warmer leak resolved; Drip under the water station and vent covering this area; The right door handle on the ice cream freezer; The vent directly above the ice cream freezer; The heating elements above the steam table; The drip from the faucet in the back section of the kitchen at the three compartment sink; The floor directly under the sink in the dishwashing area; The walls, floor, and ceiling of the Janitor's closet; All doors and door Jamb paint and gouges; The door leading from the dining room into the kitchen; Damaged flooring throughout the kitchen with black or brown build up; Drawers and cabinet doors within the stainless-steel work areas; Areas in the ceiling with paint peeling, trim peeling from adjacent walls, and ceiling panels; light fixtures missing light bulbs; Gouges & chipped paint on pillars, baseboards, and walls in the dining room.

All areas corrected in the Kitchen: All food items were covered and dated; All five gallon ice cream tubs covered; Scoops were removed from all food storage bins; Powdered sugar drawer eliminated; All dirty items were removed from storage alongside clean items; The meat slicer and stand up mixer were covered; The mop bucket is emptied each shift and as mop water becomes dirty; Lids were placed on all garbage containers;

All items removed from the Kitchen: All cutting boards with deep grooves and score marks were removed; The wood food prep table was removed; stiff, dirty towels were removed from the Janitor's closet sink; All dining room chairs with damaged seats or loose backs were removed.

All Dietary staff inserviced on cleaning routines with a cleaning binder in place for cleaning routines.

All Dietary staff inserviced on dating, labeling, and covering all items in refrigerators/freezers.

All Dietary staff inserviced on use of testing strips for sanitation buckets and their location.

All Dietary staff inserviced on covering the meat slicer and stand up mixer when not in use.

All Dietary staff inserviced on not storing scoops in food storage bins.

Posted sick policy specific to kitchen staff and all staff inserviced on this policy.

The kitchen and dining room evaluated for cleanliness and repairs weekly for the next 3 months by Dietary Supervisor, ED, and Maintenance Director.

Any cleaning or repair issues found will be brought to QA for further review.

2. Resident 1 was admitted to facility in 01/2024 with diagnoses including Type 2 diabetes, blindness, and mental disorder.  

The current service plan dated 02/29/24 and Temporary Service Plans were reviewed. The resident and care staff were interviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Nail care;   

* Ambulation assistance needed;

* Where the resident ate his/her meals;

* Evacuation status;

* Activity assistance needed;

* Memory relating to the assistance needed from staff with ADLs;

* What staff should monitor for relating to signs and symptoms of high and low blood sugar;

* Behaviors relating to toileting; and

* Verbal cues for transferring into a wheelchair.

The need to ensure the service plan was reflective of the resident's current status and included clear directions to staff was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.   

a. The current service plan dated 12/21/23 had not been updated quarterly.

b. The current service plan and Temporary Service Plans were reviewed. The resident and care staff were interviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Short term memory loss;

* Behavior interventions;

* Ability to make needs known;

* The use of a white board to remind the resident what time to attend meals;

* Where the resident ate his/her meals;

* Evacuation status;

* Fall interventions and instructions on how to monitor them, including non-slip strips beside the bed and a bed cane;

* What staff should monitor for relating to signs and symptoms of high and low blood sugar;

* Staff status checks; and     

* Who provides the resident's protective undergarments.

The need to ensure the service plan was reflective of the resident's current status and included clear directions to staff was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and Type 2 diabetes.

a. The current service plan dated 12/18/23 had not been updated quarterly.

b. The current service plan and Temporary Service Plans from 01/27/24 to 02/29/23 were reviewed. The service plan was not reflective of the resident's current status or did not provide clear direction to staff in the following areas:

* Preference on meals delivered to room on days Resident 3 had dialysis;

* History of open area on coccyx; and

* Days of the week Resident 3 attended dialysis.

The need to ensure service plans were completed quarterly, were reflective of resident's current needs and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. The findings were acknowledged.   

5. Resident 5 was admitted to facility in 11/2023 with diagnoses including Parkinson's disease.

The current service plan dated 02/29/24 and Temporary Service Plans from 01/02/24 to 04/01/24 were reviewed. The service plan was not reflective of the resident's current status, did not provide clear direction to staff and/or was not being implemented in the following areas:

* Communication options that included thumbs up/thumbs down;

* Frequency of status checks;

* Evacuation status; and

* Use of wheelchair for mobility.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were implemented was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. The findings were acknowledged.   

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were updated quarterly for 2 of 5 sampled residents (#s 4 and 5), were reflective of the residents' needs or provided clear direction regarding the delivery of services and services were implemented for 5 of 6 sampled residents (#s 1, 2, 3, 4, and 5) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including congestive heart failure.

The current service plan, dated 02/26/24, was reviewed. Observations and interviews with staff and Resident 2 were completed during the survey.

The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Oxygen use, including rate of oxygen flow and frequency of use;

* Vision including low vision status with appropriate assistance level required from staff;

* Shower location preference; and

* Use of siderails and siderail precautions.

The need to ensure service plans were reflective of resident's current status and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 2's service plan was updated with: Oxygen use, including rate of oxygen flow and frequency of use; Vision including low vision status with appropriate assistance level required from staff; Shower location preference; and Use of siderails and siderail precautions.

Resident 1's service plan was updated with: Nail care;

Ambulation assistance needed; Where the resident eats his meals; Evacuation status; Activity assistance needed; Memory relating to the assistance

needed from staff with ADLs; What staff should monitor for relating to signs and symptoms of high and low

blood sugar; Behaviors relating to toileting; and Verbal cues for transferring into a wheelchair.

Resident 4's service plan was updated with: Short term memory loss; Behavior interventions; Ability to make needs known; The use of a white board to remind the

resident what time to attend meals; Where the resident ate his/her meals; Evacuation status; Fall interventions and instructions on how to monitor them, including non-slip strips beside the bed and a bed cane; What staff should monitor for relating to signs and symptoms of high and low blood sugar; Staff status checks; and Who provides the resident's protective undergarments.

Resident 3's service plan was updated with: Preference on meals delivered to room on days Resident 3 had dialysis; History of open area on coccyx; and Days of the week Resident 3 attended dialysis.

Resident 5's service plan was updated with: Communication options that included thumbs up/thumbs down; Frequency of status checks; Evacuation status; and Use of wheelchair for mobility.

ED, ALD, & RN inserviced on the required components of a service plan, and the need to ensure service plans are completed quarterly and are reflective of a resident's current status and include clear direction to staff.

ED, ALD, & RN inserviced on the requirement for evacuation status and plan for all residents going forward.

All service plans were reviewed for all required components and to ensure they were reflective of resident's current status.

Service plans audited for accuracy of residents needs and providing clear direction and that services were implemented as they come due for 3 months  and 3 times weekly for implementation by the LN or designee.

Audits will be brought to QA for review for 3 months.

2. Resident 1 was admitted to facility in 01/2024 with diagnoses including Type 2 diabetes, blindness, and mental disorder.  

The resident's progress notes dated 01/31/24 through 02/05/24 and the service plan dated 02/29/24 were reviewed. Resident 1 and staff were interviewed.

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

* Newly admitted to the facility; and

* Behaviors relating to his/her feces.  

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.  

The resident's progress notes dated 12/14/23 through 03/01/24, the service plan dated 12/21/24, and Temporary Service Plans were reviewed. Resident 4 and staff were interviewed.                                                                            

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

* 01/04/24: The resident reported "not feeling well";

* 01/23/24: Inappropriately touching a resident of the opposite gender;

* 02/05/24: Fall with injury;

* 02/09/24: Staff documented in a progress note, "Resident has been out of Trulicity [for diabetes] for about a month now."  

* 02/18/24: Resident to resident altercation;

* 02/20/24: Return from the hospital;

* 02/20/24: Increased confusion and memory loss; and

* 03/27/24: Discontinuation of the resident's 8:00 pm pain medication.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

4. Resident 3 admitted to the facility in 09/2023 with diagnoses including end stage renal disease and Type 2 diabetes.

The resident's current service plan dated 12/28/23, Temporary Service Plans, progress notes dated 01/11/24 through 04/04/24 were reviewed. Interviews with caregivers were completed between 04/01/24 and 04/04/24.

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

* 01/18/24: Open area to coccyx; and

* 03/08/24: Return from hospital after episode of blood in the urine.

The need to ensure resident-specific actions or interventions for short term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure short term changes of condition were evaluated, actions or interventions communicated to staff on each shift, resident specific interventions were determined and documented, and the condition was monitored with weekly progress noted until resolution for 4 of 6 sampled residents (#1, 3, 4, and 5) who experienced short term changes in the areas of skin,  move-in, and resident to resident incidents; and failed to evaluate and monitor service plan interventions for 1 of 1 sampled resident (#5) who had repeated falls. Resident 5 continued to have falls. Findings include, but are not limited to:

1. Resident 5 was admitted to facility in 11/2023 with diagnoses including Parkinson's disease.

Observation of Resident 5, interviews with staff and review of the resident's 02/29/24 service plan, 01/02/24 through 03/27/24 Temporary Service Plans (TSPs), progress notes, and incident investigations were reviewed.

Fall prevention interventions listed on the 02/29/24 service plan included reminding Resident 5 to use his/her pendent before ambulation. When Resident 5 has "freeze ups" staff should ensure all walking areas were free of any fall hazards, s/he was using a walker or wheelchair at all times, and proper foot wear was being worn while ambulating or transferring. Staff were instructed to provide safety checks eight times per shift. Additionally, Resident 5 required "1 person stand by assist for all ambulation."

a. Resident 5 experienced the following unwitnessed 15 falls between 01/02/24 and 03/27/24:

* 01/02/24: Fall with abrasion to right cheek;

* 01/16/24: Non-injury fall, reported leg cramps and slid out of chair;

* 01/26/24: Non-injury fall, fell packing bags;

* 01/27/24: Fall with abrasion to mouth, and complaint of hip and back pain;

* 02/06/24: Non-injury fall, freezing episode and fell near sink;

* 02/06/24: Fall with cut to cheek, fell out of recliner;

* 02/08/24: Non-injury fall, found on back, walker not near him;

* 02/09/24: Non-injury fall, found on right side not using walker;

* 02/19/24: Non-injury fall, slid out of chair;

* 02/27/24: Non-injury fall in bedroom;

* 02/27/24: Non-injury fall in bedroom;

* 03/09/24: Fall with left flank pain, swelling of feet and left shoulder and arm pain;

* 03/19/24: Non-injury fall, on hands and knees in bathroom;

* 03/23/24: Non-injury fall, lying on his/her side on floor by bed; and

* 03/27/24: Non-injury fall, sitting on floor next to chair.

On 01/02/24 the facility TSP instructed staff  to "watch for and report to nurse any of the following: any complaints of pain, discomfort or new injuries as a result of the fall." Staff were also instructed to observe the resident and report any discoloration resulting from the fall and take vitals.

Although the facility completed additional TSPs for additional falls on 01/16/24 through 02/27/24, no new interventions were developed to help prevent possible future falls.

During an interview on 04/04/24, Staff 15 (Resident Assistant) stated that she provided safety checks every two hours because there were other residents that also needed her assistance. In addition, during interviews on 04/04/24 Staff 14 (Resident Assistant) and Staff 15 were not aware that Resident 5 had a wheelchair to use as an option for his/her mobility.

During an observation on 04/03/24 Resident 5 was observed to walk with a walker from his/her room, ambulated down the hallway, entered and exited the elevator to the third floor dining room with no assistance from staff.  

There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall.

During an interview on 04/03/24 at 12:00 pm, Staff 8 (RN) confirmed there was no additional documentation for review.

b. TSPs were created, but progress was not documented at least weekly through resolution, for the following short-term changes of condition:

* 01/02/24: Fall and abrasion to right cheek;

* 01/27/24: Abrasion to mouth; and

* Non-injury falls: 02/06/24 (two), 02/08/24, 02/09/24, and 03/19/24.

The need to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 on 04/04/24. They acknowledged the findings.

RN to complete a comprehensive Review of Resident 5 relating to his fall, Tsp, intervention, safety checks and apporpriate interventions.

RN to complete a comprehensive review of Resident 1 relating to behaviors and interventions for staff to care for the resident.

RN to complete a comprehensive assessment of Resident 4 to ensure all documentation of resident specific actions and interventions are documented.

RN to complete a comprehensive assessment of Resident 3 to ensure actions and interventions are clear and specific to the resident.

ED, ALD, RN & Med Techs were inserviced on incident reporting to ensure every incident report has an intervention put in place to prevent further incidents.

ED, ALD, & RN were inserviced to ensure monitoring of fall prevention interventions at the time of each fall and monitoring for patterns related to the falls, to determine and document what new interventions are needed for a resident subsequent to each fall.

ED, ALD, & RN were inserviced on TSP's to ensure residents who had short term changes of condition were evaluated and that resident specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was

monitored at least weekly through resolution.

Changes of condition monitored 2x week by ED or designee for three months.

All findings relating to changes of condition brought to QA for review for three months.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 1 and 4) who received weekly insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

a. During the acuity interview on 04/01/24, it was identified that Residents 1 and 4 received insulin injections by unlicensed staff (MAs) weekly. The delegations for Staff 10 (MA) and Staff 26 (MA) lacked the following information:  

* If the resident did or did not require assessment during the procedure;

* The procedure did not require interpretation or independent decision making;

* Results of the procedure were reasonably predictable;

* The procedure was not life-threatening and delegation posed minimal risk to the resident;

* The resident's environment supported safe performance of the procedure;

* The procedure will be performed by unlicensed staff at a frequency that allows for continued safe performance;

* Availability of the RN to provide on-going assessment of the resident at a frequency deemed necessary to determine on-going stability and predictability;

* Observations of the resident including desired effects, side effects, potential adverse reactions, and emergencies;

* Direct observation of the unlicensed staff in their performance of procedure;

* Whether the RN had previously authorized the same unlicensed staff for the same procedure;

* The resident's responses to actual or potential heath problems that may impact the resident's response to the delegated condition;

* Documentation of the length of the unlicensed staff's authorized period and data supporting that decision;

* Documented recommendations on how the resident would continue to receive the procedure if the RN was no longer a member of the health care team and the procedure remained ordered for the resident; and

* Update the service plan to identify the procedure had been delegated.

b. Review of Resident 1's delegation documentation revealed the following:

* There was no documented evidence the RN had collected resident specific data prior to determining residents condition was stable and predictable;

* Initial delegation for Staff 10 (MA) was dated 02/01/24. Resident 1's MAR indicated no injection had been scheduled or was administered on that date; and

* Initial delegation for Staff 26 (MA) was dated 03/21/24. Resident 1's MAR indicated no injection had been scheduled or was administered on that date.

c. Review of Resident 4's delegation documentation during the survey revealed the RN copied her determination that the client's condition was stable and predictable from her 11/30/23 assessment to the 03/01/24 assessment, although the information provided in 11/2023 was different relating to the blood sugar data and the name of the medication that the unlicensed staff would be administering.

Staff 26 was delegated on 03/21/24, but the documentation on the 03/2024 MAR revealed she administered the injection on 03/07/24.

The RN documented Staff 10 and Staff 26 were to be re-delegated in 90 days from their initial delegation.

In an interview on 04/03/24 at 12:15 pm, Staff 8 (RN) confirmed she was unaware the initial re-delegation evaluation must be completed within 60 days of the initial delegation.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director) and Staff 8 on 04/03/24. They acknowledged the findings.  

RN no longer works ar this community. Interm RN to do oversite on Calaroga Terrace.

RN reviewed all Med Tech's delegations and redelegated staff as necessary to ensure all required elements and information were included for each resident.

RN reviewed each delegated resident's current delegation documents to ensure all required elements were present as required per Division 47 for Nurse Delegation and made corrections as necessary.

After RN review, all delegation documents were reviewed by ED or designee to ensure completion & accuracy for two months.

All new delegations and redelegations will be brought to QA team to review for two months.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, staff were informed of new interventions and the service plan was adjusted if necessary, and reporting protocols were in place for 3 of 4 sampled residents (#s 2, 3, and 5) who received outside services. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 05/2023 with diagnoses including congestive heart failure.

Progress notes and outside provider notes dated 01/03/24 to 02/26/24, service plan dated 02/26/24, and Temporary Service Plans were reviewed.

There was no documented evidence staff were informed of new interventions, and the service plan was updated for the following recommendation:

* 02/01/24 - HH RN noted, "[patient] agreeable with obtaining weights prior to shower."

The need to ensure staff were informed of new interventions and the service plan was updated as necessary after on-site health services were provided was discussed on 04/04/24 with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN). They acknowledged the findings.

2. Resident 3 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and Type 2 diabetes.

A review of Resident 3's clinical record revealed on 01/21/24, Staff 8 (RN) had documented an open area on the resident's buttock on a Skin Integrity Monitoring Form, notified the physician, and requested home health to evaluate the area.

The next documented entry on 02/01/24 revealed an outside provider was providing care for the resident's "open wound on coccyx area."

During an interview on 04/02/23 at 12:40 pm, Staff 8 indicated an outside provider provided wound care for Resident 3 until the area resolved on 02/21/24. She stated she attempted to observe the area with the provider when the resident had a scheduled visit, then she documented notes on the Skin Integrity Monitoring Form. After the visit, the outside provider completed a form with any recommendations, Staff 8 reviewed the documentation, and a MA transcribed the note into the narrative charting.

There was no documented evidence an outside provider had provided services to the resident, nor was the resident's service plan updated to include the open area.

The lack of documentation of coordination of care with outside providers was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 on 04/04/24. They acknowledged the findings.

3. Resident 5 was admitted to facility in 11/2023 with diagnoses including Parkinson's disease.

A review of Resident 5's progress notes revealed on 02/09/24 Resident 5 was being discharged from the hospital and "they are going to put a referral in for home health OT."

There was no further documentation to confirm if Resident 5 received home health OT.

During an interview on 04/03/24 at 12:00 pm with Staff 8 (RN), she acknowledged the hospital stated they would order HH OT, and the facility did not coordinate outside provider services when they are ordered at the hospital. She confirmed Resident 5 did not have home health OT.

The lack of documentation of coordination of care with outside providers was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 on 04/04/24. They acknowledged the findings.

Resident 2's service plan updated per HH RN's note regarding resident's preference.

Facility requested documentation from outside provider for services provided to Resident 3 and service plan updated. RN to review skin for any issues and send to physcian for HH order if needed.

Facility followed up with Resident 5's PCP to request order for OT.

ED, ALD, & RN, were inserviced on outside provider notes, how to communicate them with staff and that they are a part of the chart.

Outside Provider notes and orders reviewed 3x weekly for two months by LN or designee.

Audits brought to QA for two months for review.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#3) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and sciatica.

The resident's physician orders, the Controlled Substance Disposition logs, and the MAR, dated 03/01/24 through 04/01/24 were reviewed.

The resident had a physician order for oxycodone (a pain reliever) 5 mg one tablet by mouth every six hours as needed for pain (for pain unrelieved by non-opioid agents).

The following inaccuracies were identified between the resident's MAR and the Controlled Substance Disposition log:

a. On 03/15/24 and 03/26/24, Resident 3's PRN oxycodone was documented as administered in the Controlled Substance Disposition log, but it was not documented in the MAR.

b. On 03/16/24, Resident 3's PRN oxycodone was documented as administered on three occasions in the Controlled Disposition log, but it was documented as administered twice in the MAR. On 03/17/24, Resident 3's PRN oxycodone was not documented as administered in the Controlled Substance Disposition log, but it was documented as administered in the MAR.

The records were reviewed with Staff 2 (Assisted Living Director) on 04/03/24 at 12:40 pm. It was determined the incorrect date was entered for the third dose of the oxycodone on 03/16/24, and the medication was administered on 03/17/24 at 8:00 pm.

The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1 (ED), Staff 2, and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 3's MAR/Chart Notes were updated to include  corrections regarding the inaccuracies between the resident's MAR and the Controlled Substance Disposition log.

Med Techs were inserviced on the Narcotics count in the Controlled Substance Dispostion log matching the EMAR.

Narcotic audit conducted 3x weekly by the ALD or designee for two months.

Narcotic Audits will be brought to QA monthly for review.

2. Resident 1 was admitted to the facility in 01/2024 with diagnoses including hypertension, Type 2 diabetes, psoriasis, and blindness.

The resident's MARs, dated 02/01/24 through 04/01/24, corresponding progress notes, and prescriber orders were reviewed.

The following medications and treatments were not administered as the medication was not available to staff:

* Sarna lotion (for itching) twice on 02/01/24;

* MAG64 (a supplement) from 02/01/24 through 02/05/24;

* Lubriderm lotion (for skin health) on 02/01/24;

* Melatonin (for sleep) on 02/02/24; and

* Olmesartan (for blood pressure) on 03/05/24.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.  

The resident's MARs, dated 02/01/24 through 04/01/24, corresponding progress notes, and prescriber orders were reviewed.  

The following medications and treatments were not administered as the medication was not available to staff:

* Trulicity injection pen (for diabetes);

* Trazodone (for insomnia);

* Lancets (to test blood sugar);

* Multivitamin (a supplement); and

* Gabapentin (for nerve pain).

The following medications and treatments were not administered as staff "could not locate [the] resident" on 04/01/24 at 7:48 am:

* Aspirin (for heart health);

* Magnesium (a supplement);

* Metformin (for diabetes);

* Vitamin B 12 (a supplement);

* Duloxetine (for depression and neuropathy);

* Polyethylene glycol (for constipation);

* Multivitamin;

* Gabapentin; and

* Lancets.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 3 of 5 sampled residents (#s 1, 3, and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease, hypertension, and Type 2 diabetes.

Resident 3's MARs, dated 03/01/24 through 04/01/24, and corresponding progress notes and prescriber orders were reviewed and revealed the following:

a. The resident had an order for Carvedilol 6.25 mg (for blood pressure) to be administered one tablet two times daily. If the systolic blood pressure was less than 110 or if the heart rate was less than 60, the order stated to hold medication dose one time a day and to hold on dialysis days.

* The blood pressure and heart rate were not taken on 24 occasions prior to the administration of Carvedilol; and

* Carvedilol was administered on 03/24/24 when the heart rate was less than 60.

b. Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the medication was not available:

* Finasteride 5 mg (for benign prostatic hypertrophy): 03/01/24 through 03/07/24;

* Heal-N-Soothe (a supplement): 03/01/24 through 03/20/24;

* Prednisone 5 mg (for inflammation): 03/01/24 through 03/05/24;

* Tamsulosin HCL 0.4 mg (for urination): 03/01/24 through 03/09/24; and

* Sertraline 50 mg (for depression): 03/01/24 through 03/02/24.

During an interview on 04/03/24 at 10:40 am, Staff 11 (MA) confirmed the medications were not administered during those time frames.

c. The resident had an order dated 03/10/24 for staff to check blood pressure daily for one week then fax weekly readings to primary care provider and to notify doctor's office if blood pressure is greater than 180/100 or less than 90/50.

* There was no documented evidence blood pressure was taken on 03/18/24; and

* There was no documented evidence the facility notified the prescriber when the blood pressure was outside of parameters on 03/24/24 and 03/30/24.

The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 3 blood pressure meds and ranges corrected, RN to review on missed medications physcian to be notified, risk management to be done and reported, all time medications were given our side of parameters or medications missed were reported to physicain.

Resident 1 RN to review of all medications missed, risk management to be completed and self reported. Physician to be notified.

Resident 4, RN to do a review of all medications missed, Risk management to be competed and reported to state. Physicain to be notified.

Med Techs were inserviced on medications with parameters, how to record parameters, and when to notify the facility physcian.

Med Techs, ALD, & RN were inserviced on what to do when a medication is unavailable to be administered.

Daily medication administration reports will be run to ensure administration of all medications was completed by ALD or designee 3x a week for two months.

All audits with missing medication administration will be immediately reviewed and addressed with each resident's PCP and brought to QA for further review. for two months.

2. Resident 1 was admitted to the facility in 01/2024 with diagnoses including hypertension, Type 2 diabetes, psoriasis, and blindness.

The resident's MARs, dated 02/01/24 through 04/01/24, corresponding progress notes, and prescriber orders were reviewed and revealed Resident 1 refused to consent to the following orders on multiple occasions:

* Erythromycin ointment (for eye health);

* Hydrocortisone cream (for skin health);

* Triamcinolone ointment (for skin irritation);

* Lubriderm lotion (for skin health);

* Sarna lotion (for itching);

* Polyethylene glycol (for bowel care);

* Timolol solution (for eye pressure);

* Gabapentin (for diabetic neuropathy); and

* Melatonin (for insomnia).

Although there was documentation staff "faxed [the physician]" on 03/17/24 relating to Resident 1's refusal of Lubriderm, polyethylene glycol, and Sarna lotion, Staff 2 (Assisted Living Director) confirmed there was no additional documented evidence the facility notified the resident's 1's physician of the refusals on 04/02/24 at 12:02 pm.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2, and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.  

The resident's MARs, dated 02/01/24 through 04/01/24, corresponding progress notes, and prescriber orders were reviewed and revealed Resident 4 refused to consent to the following orders on multiple occasions:

* Ozempic pen (for diabetes);

* Lancets (for checking blood sugar);

* Gabapentin (for nerve pain); and

* Polyethylene glycol (for bowel care).

On 04/03/24 at 1:03 pm, Staff 13 (MA) stated that they try to administer the medication three times prior to documenting "resident refused." She reported there was a "refusal paper" that staff would fill out "sometimes" and place the paper in the back of the resident's chart.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

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 an order, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) with documented medication and treatment refusals. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including obesity.

Resident 2's 03/01/24 through 04/01/24 MARs, 03/01/24 physician's orders, and 03/01/24 through 04/01/24 weekly weight records were reviewed and showed Resident 2 had an order for weekly weights with instruction to notify the provider when his/her weight had increased by three or more pounds in one week. The resident was noted to have refused to have his/her weight obtained on 03/25/24 and 04/01/24.

In an interview with Staff 25 (MA) on 04/04/24, she reported Resident 2 often refused to have his/her weight obtained.

There was no documented evidence the facility notified the provider when the resident refused to have his/her weight obtained on 03/25/24 and 04/01/24.

The need to notify the provider when Resident 2 refused to consent to an order was reviewed with Staff 1 (ED), Staff 2 (Assisted Living Director) and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 09/2023 with diagnoses including end stage renal disease and Type 2 diabetes.

The resident's MARs, dated 03/01/24 through 04/01/24, were reviewed and revealed facility staff documented Resident 3 refused the following orders:

* Fluticasone nasal spray (for allergies) two times;

* Cyclosporine (for dry eye) 25 times;

* Calprotect ointment (for sore) 23 times; and

* Blood pressure one time.

In an interview on 04/03/24 at 12:45 pm, Staff 2 (Assisted Living Director) confirmed there was no documented evidence the facility notified Resident 3's physician of the refusals.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED), Staff 2, and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 2- Physician notified of resident refusing weights.

Resident 1- Physician notifed of muliple medication refusals, and 4/2 refusal

Resident 4- Physician notified of medication refusals.

Resident 3 Physicain notified of medication refuals.

A comprehensive audit of resident's MAR's will be completed to identify resident refusals of Physician's, physican will be notified of all refusals.

All Med Tech's, ALD, and RN were inserviced on resident refusals of Physician's Orders and the need to notify the physician when a resident refuses to consent to an order.

Weekly 2x for 2 months MAR audits will be performed for all resident's  by the ALD or designee to ensure physician's have been notified of resident refusals of orders.

Results of audits will be brought to QA for two months for review.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 4 of 5 sampled residents (#s 1, 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 05/2023 with diagnoses including pulmonary emphysema.

The resident's 03/01/24 through 04/01/24 MARs and physician's orders were reviewed and identified the following:

* Bisacodyl 10 mg suppository, insert one daily PRN (for constipation);

* Milk of Magnesia 400 mg, take 20 ml daily PRN (for bowel care);

* Ipratr/albut 0.5-2.5 mg/ml inhale contents of one vial via nebulizer every six hours PRN (for wheezing or shortness of breath); and

* Albuterol, inhale two puffs into the lungs every six hours PRN (for wheezing).

The PRN medications for bowel care and wheezing lacked resident-specific parameters for the sequential order of use.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director) and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 01/2024 with diagnoses including hypertension, Type 2 diabetes, psoriasis, and blindness.

The resident's MARs, dated 02/01/24 through 04/01/24, and prescriber orders were reviewed and identified the following:

* Hydrocortisone cream (for skin care);

* Triamcinolone ointment (for skin care);

* Genteal eye gel (for eye health); and

* Refresh drops (for eye health).

The PRN medications for skin care and eye health lacked resident-specific parameters for the sequential order of use.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director) and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

3. Resident 4 was admitted to the facility in 03/2023 with diagnoses including Type 2 diabetes and dementia.  

The resident's MARs, dated 02/01/24 through 04/01/24, and prescriber orders were reviewed and identified the following:

* Acetaminophen (for pain) 325 mgs;  

* Acetaminophen 500 mgs;

* Aspercreme (for muscle pain); and

* Icy Hot roll-on (for muscle pain).   

The PRN medications for pain and muscle pain lacked resident-specific parameters for the sequential order of use.

The requirement for MARs to be accurate, including resident-specific parameters for PRN medications, was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director) and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

4. Resident 5 was admitted to facility in 11/2023 with diagnoses including Parkinson's disease.

Resident 5's 03/01/24 through 04/01/24 MARs were reviewed during the survey and found to be lacking instructions for the following PRN medications:

* Carbidopa/Levodopa 25 mg/100 mg to administer 1-2 tablets four times daily for freezing; and

* Ropinirole 0.5 mg to administer 1-2 tablets at bedtime for Parkinson's.

There were no further instructions clarifying when to administer one tablet versus two tablets of the medications.

The need to ensure the MARs were accurate and included instructions for PRN medications was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24. They acknowledged the findings.

Resident 2, All prns were review for specific parametes and put in sequentail order.

Resident 1, All skin care and eye health orders were reviewed for specific parameters.

Resident 4, All Pain meds and muscle pain meds were reviewed for parameters and sequential order.

Resident 5, All medications that state 1-2 tabs were updated to claifying when to administer 1 vs. 2 tabs.

An audit of all resident's PRN orders will be performed to ensure specific parameters, to ensure directions for sequential order of use or if the resident is able to self-direct, and to ensure clear directions for when to give one versus two tablets.

All Med Techs, ALD, and Nurse will be inserviced on the requirements of a complete PRN order to ensure clear instructions for use.

New PRN orders will be audited 2x a week for 2 months by LN or Designee two times weekly for three months by reviewing daily charting and incident reports and investigations.

Results of audits will be brought to QA for two months further review.

Based on interview and record review, it was determined the facility failed to review the Acuity Based Staffing Tool (ABST) for each resident no less than quarterly and to use the results to develop and routinely update the facility's staffing plan. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 2 (Assisted Living Director) on 04/02/24 at 10:00 am.

a. One unsampled resident was not included in the ABST.

b. Two of six sampled and unsampled residents' ABST did not show evidence of being updated at least quarterly. Additionally, the proprietary ABST Community Dashboard documentation revealed there were 16 service plans past due.

During an interview on 04/02/24 at 10:05 am, Staff 2 stated she was using the ABST to develop and update the facility's staffing plan. However, the data in the ABST was not up to date to accurately reflect the amount of staff time needed to meet the 24-hour scheduled and unscheduled needs of the residents.

The need to ensure residents' ABST was reviewed no less than quarterly and the tool was used to develop and update the facility's staffing plan was discussed with Staff 2 on 04/02/24. She acknowledged the findings.

The ABST will be audited to ensure all residents are included in the ABST and used to develop the facility staffing plan.

ALD inserviced on the requirement of resident's ABST being updated quarterly along with the resident's service plans to ensure the facility's staffing plan is updated and accurately reflects the amount of staff time needed to meet resident's needs.

The ED or designee will review and update the ABST weekly along with the resident's service plans.

Audits of the ABST and resident service plans will be completed 1x weekly to ensure all residents are captured and services match the ABST correctly.

results will be brought to QA for review.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 20, 21, and 22) completed pre-service orientation training prior to beginning their job responsibilities, 2 of 3 newly hired staff (#s 20 and 22) completed all pre-service dementia training, and 4 of 17 kitchen staff (#s 18, 19, 23, and 24) who prepared and served food had an active food handler's certificate. Findings include, but are not limited to:

The facility's training records were reviewed on 04/02/24.

a. Staff 20 (MA) hired 12/29/23, Staff 21 (Resident Assistant) hired 02/20/24, and Staff 22 (Resident Assistant) hired 02/25/24, lacked documented evidence all pre-service orientation topics were trained on prior to beginning their job responsibilities in the following areas:

* Abuse and reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

b. Staff 20, 21, and 22 lacked documented evidence of a written job description.

c. Although Staff 20 and 22 had the pre-service dementia care training, it was dated on 05/19/21 and 02/11/20 respectively. The training is meant to be portable, but has a disclaimer of only being portable for 24 months after receiving the training.  

d. Staff 18 (Chef), Staff 19 (Dietary Assistant), Staff 23 (Dietary Assistant), and Staff 24 (Chef) lacked documented evidence a food handler's certificate was obtained prior to 04/01/24.  

The need to ensure staff completed all required pre-service orientation training prior to beginning job duties and kitchen staff who prepared and served food had an active food handler's certificate was discussed with Staff 1 (ED), Staff 2 (Assisted Living Director), Staff 5 (Business Office Manager), and Staff 6 (Dietary Supervisor) on 04/02/24 and 04/03/24. They acknowledged the findings.

An audit of all staff will be performed to ensure all required pre-service training and oreintation, food handler's certificates, and written job descriptions are completed and on file.

ED, ALD, Dietary Supervisor, and Business Office Manager inserviced on requirement for pre-service orientation, training, and job descriptions for all employees.

Staff training and certifications will be audited monthly by ALD, BOM, or designee.

Results of the audits will be brought to QA monthly for review and follow up.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 20, 21, and 22) had verification of demonstrated satisfactory performance in any duty they were assigned within thirty days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 04/02/24.

There was no documented evidence Staff 20 (MA) hired 12/29/23, Staff 21 (Resident Assistant) hired 02/20/24, and Staff 22 (Resident Assistant) hired 02/25/24, demonstrated competency within 30 days of hire in one or more of the following areas:

* The role of service plans in providing individualized resident care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification, documentation, and reporting changes of condition;

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

* General food safety, serving and sanitation;

* Other duties as applicable (medications and treatments); and

* First Aid/abdominal thrust training.

On 04/03/24 at 1:59 pm, Staff 2 (Assisted Living Director) confirmed Staff 20 would not be passing medications or providing treatments to residents until she had documented evidence of the above training.

The need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2, and Staff 5 (Business Office Manager) on 04/02/24 and 04/03/24. They acknowledged the findings.

An audit of all direct care staff was performed to ensure competency has been satisfactorily demonstrated and documented for assigned duties.

ALD, ED, and Business Office Manager inserviced on the need to ensure documentation that newly hired staff completed training and demonstrated competency in all assigned duties within 30 days of hire.

Direct Care Staff training and competency documentation audited 3x monthly for 3 months by ALD or designee to ensure completion.

Results of audits will be brought to QA monthly for further review.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term, non-direct care staff (#s 16 and 17) completed the annual infectious disease training. Findings include, but are not limited to:

Staff training records were reviewed on 04/02/24.

Staff 16 (Housekeeping) and Staff 17 (Activities) lacked documented evidence they completed the annual infectious disease training.

The need to ensure long term, non-direct care staff completed the infectious disease training annually with discussed with Staff 5 (Business Office Manager) on 04/02/24 at 2:07 pm. She acknowledged the findings.

An audit of non-direct care staff will be completed to ensure completion of annual infectious disease training.

ED and BOM inserviced on the requirement non-direct care staff to complete annual infectious disease training.

Annual infectious disease training documentation audited 2x monthly for 2 months by BOM or designee to ensure completion.

Results of audits will be brought to QA monthly for further review.

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

Facility fire drill records dated 10/2023 through 04/2024 were reviewed with Staff 3 (Plant Operations Supervisor) on 04/03/24. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:

* Date and time of the fire drill;

* Location of simulated fire;

* 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.

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

The need to ensure unannounced fire drills were conducted every other month and included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills, was discussed with Staff 1 (ED) on 04/04/24. He acknowledged the findings.

Unannounced fire drill to be conducted during current month to ensure all required components of fire drills are included with evacuation routes. Fire & Life Safety training to be conducted in subsequent month. Drills and trainging to be conducted in alternate months thereafter.

ED & Maintenance Director inserviced on the requirement of Fire Drills being conducted every other month including all required components to alternate monthly with Fire & Life safety training.

Fire Drills and Fire & Life Safety Training  audited monthly for 3 months for completion by ED or designee.

Results of audits will be brought to QA monthly.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

In a 04/03/24 interview with Staff 1 (ED), fire and life safety records were reviewed and the following was identified:

When asked to provide documentation of fire and life safety instruction provided to residents within 24 hours of admission and the re-instruction provided at least annually, he confirmed a written record of fire safety training, including content of the training sessions and the residents attending could not be located.

The facility lacked documented evidence residents were instructed 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 within 24 hours of admission and at least annually.

On 04/04/24, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and re-instructed at least annually as required by the Oregon Fire Code was discussed with Staff 1 and Staff 2 (Assisted Living Director). They acknowledged the findings.

Education to be provided to all residents with documented evidence of general safety procedures, evacuation methods and routes, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

ED & ALD inserviced on the requirement to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re- instructed at least annually.

Fire & Life Safety instruction will be provided by ALD or Designee at least quarterly with each residents service plan. Service plans audited for insturction by ED or designee 2x weekly for 2 months.

Audits of all residents Fire & Life Safety instruction will be brought to QA for two months.

Based on observation and interview, it was determined the facility failed to ensure the grounds were free of litter and refuse, and the exterior pathways were made of hard, smooth material and maintained in good repair. Findings include, but are not limited to:

Observations of the facility exterior on 04/02/24 identified the following:

* A bag of garbage, a half empty plastic cup, and discarded mail material was left on the terrace patio; and

* Multiple drop-offs of two to three inches were noted along pathway edges on the south and east side of the building and near the front entrance sign, which presented a fall hazard.

The need to ensure grounds were free of litter and refuse and outside surfaces were maintained in good repair was discussed with Staff 1 (ED) and Staff 3 (Plant Operations Supervisor) on 04/03/24. They acknowledged the findings.

All garbage and discarded material was was picked up from the terrace patio and bark was ordered and installed to ensure no drop-offs along the edges of pathways on the South and East sides of the building and near the front entrance sign. Grounds were checked and free of litter.

Exterior grounds and pathways will be walked daily by Maintenance Director or designee to ensure safety and cleanliness. 2x Weekly walk throughs of exterior grounds to be conducted by ED for 2 months.

Areas needing to be addressed will be brought to the ED when identified.

All items to be brought to QA monthly.

Based on observation and interview, it was determined the facility failed to ensure the design of the Residential Care Facility (RCF) supported the installation of handrails at one or both sides of resident-use corridors. Findings include, but are not limited to:

The interior of the building was toured on 04/02/24. Corridors to resident rooms from common areas and elevators were observed without a handrail on at least one side of the corridors on the seventh floor.

The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (ED) and Staff 3 (Plant Operations Supervisor) on 04/03/24. They acknowledged the findings.

Handrails will be installed in the corridors to resident rooms from common ares and elevators on at least one side of the corridors on the seventh floor.

ED & ALD and maintenace informed that handrails must be installed in the corridors to resident rooms from common ares and elevators on at least one side of the corridors on the seventh floor.

The missing handrails will be monitored until installation is completed.

ED, ALD, & Maintenance Director will ensure this correction is completed.

Any other missing handrails will be reported to ED and brought to QA for review.

Based on observation and interview, it was determined the facility failed to ensure lever-type door handles were provided on all doors used by residents, the interior of the facility was free from unpleasant odors, and the environment was clean and maintained in good repair. Findings include, but are not limited to:

The residents in RCF reside on floors four through seven. The facility was toured on 04/02/24 and the following was observed:

a. Exterior of building:

* The terrace had multiple areas of black, white, and green debris on the ground, the top of cement edges surrounding a planter by the exit door had chipped paint, and multiple pieces of patio furniture were covered with dirt, debris, and/or were broken;

* Multiple doors exiting onto the terrace were covered in clear plastic material; and  

* The fourth floor patio had multiple areas with bird droppings and lint debris.

b. Facility wide:

* Multiple chairs were torn and/or peeling;

* Multiple light fixtures on the ceiling had dead insects;

* Odors of smoke and/or urine present on multiple days in the resident corridors on floors five, six, and seven; and

* Lever-type door handles were missing on doors leading into the stairwells from the platforms on floors three through seven, and missing on doors leading directly from the hallways into the stairwells and/or platforms on floors four, five, and seven.

c. Second floor resident-use laundry room:

* Missing a doorknob on a door; and

* Metal tracks suspending washing machines had an approximate two foot gap between washers with exposed rust colored debris and sharp edges.  

d. Fourth floor:

* Room 407 had a light bulb that was burned out in the entryway, the kitchen cabinet under the sink was broken and scuffs were present on the exterior door to the apartment;

* Ceiling light in hallway by Room 418 had a light bulb burned out;

* Small dining room: chipped paint in multiple areas, a broken high/low table, damage to kitchen cabinet under juice machine, radiator was broken, a handle was missing on kitchen refrigerator, and build up of dirt on the windowsill and track of sliding glass door; and

* Missing paint on the wall next to vacant office by service elevator.

e. Fifth floor:

* Laundry room: chipped and peeling paint on interior of door, pile of unknown wet linens stored on top of dryer lid;

* Trash chute was covered with tape, the handle was broken and unable to fully close;

* Scuff marks on doors to Rooms 507 and 508; and

* Small dining room: a walker and commode were being stored along the perimeter of the room, brown debris on the floor near the kitchen, and two glass vases stored on the floor next to the refrigerator.

f. Sixth floor:

* Sitting area: one chair had a worn armrest and the wood perimeter had gouges and peeling paint;

* Small dining room: multiple gouges and chipped paint on the walls;

* Laundry room had half of a ceiling tile missing with pipes exposed; and

* Chipped paint on exit door by Room 610.  

The need to ensure lever-type door handles are provided on all doors used by residents, the interior of the facility is free from unpleasant odors and the interior and exterior of the building was clean and maintained in good repair was discussed with Staff 1 (ED) and Staff 3 (Plant Operation Supervisor) on 4/3/24. They acknowledged the findings.

All identified areas/items requiring cleaning, repair, removal, or correction addressed:

a. Exterior of building: The terrace had multiple areas of black, white, and green debris on the ground, the top of cement edges surrounding a planter by the exit door had chipped paint, and multiple pieces of patio furniture were covered with dirt, debris, and/or were broken; Multiple doors exiting onto the terrace were covered in clear plastic material; and The fourth floor patio had multiple areas with bird droppings and lint debris.

b. Facility wide: Multiple chairs were torn and/or

peeling; Multiple light fixtures on the ceiling had

dead insects; Odors of smoke and/or urine present on multiple days in the resident corridors on floors five, six, and seven; and Lever-type door handles were missing on doors leading into the stairwells from the platforms on floors three through seven, and missing on doors leading directly from the hallways into the

stairwells and/or platforms on floors four, five, and seven.

c. Second floor resident-use laundry room: Missing a doorknob on a door; and Metal tracks suspending washing machines had an approximate two foot gap between washers with exposed rust colored debris and sharp edges.

d. Fourth floor: Room 407 had a light bulb that was

burned out in the entryway, the kitchen cabinet under the sink was broken and scuffs were present on the exterior door to the apartment; Ceiling light in hallway by Room 418 had a light bulb burned out;

Small dining room: chipped paint in multiple areas, a broken high/low table, damage to kitchen cabinet under juice machine, radiator was broken, a handle was missing on kitchen refrigerator, and build up of dirt on the windowsill and track of sliding glass door; and

Missing paint on the wall next to vacant office by service elevator.

e. Fifth floor: Laundry room: chipped and peeling paint on interior of door, pile of unknown wet linens stored on top of dryer lid; Trash chute was covered with tape, the

handle was broken and unable to fully close; Scuff marks on doors to Rooms 507 and 508; and Small dining room: a walker and commode were being stored along the perimeter of the room, brown debris on the floor near the kitchen, and two glass vases stored on the floor next to the refrigerator.

f. Sixth floor: Sitting area: one chair had a worn armrest and the wood perimeter had gouges and peeling paint;

Small dining room: multiple gouges and chipped paint on the walls; Laundry room had half of a ceiling tile

missing with pipes exposed; and Chipped paint on exit door by Room 610.

ED & Maintenance Director inserviced on the requirements for facility Doors, Walls, Elevators, and odors: Regarding lever-type door handles, unpleasant odors, and maintaining the environment in clean and good repair.

The identified areas of the RCF and dining room will be evaluated for cleanliness, repairs, and odors  3x weekly for the next two months by ED and Maintenance Director.

Based on observation and interview, it was determined the facility failed to ensure a lockable storage space (e.g., drawer, cabinet, or closet) was provided for the safekeeping of a resident's small valuable items and funds. Findings include, but are not limited to:

a. During a group interview on 04/02/24 at 11:00 am, six non-sampled residents stated they did not have a lockable storage space in their apartments.

b. Review of several random apartments, the apartments of sampled residents, and one unsampled resident in group indicated apartments contained a lockable drawer in the bathroom or kitchen. The locking device was removed from one apartment, leaving a hole in the drawer front. None of the residents interviewed were able to provide a key to their locking storage space.

The need to ensure residents had a lockable storage space with a key was reviewed with Staff 1 (ED), Staff 2 (Assisted Living Director), and Staff 8 (RN) on 04/04/24.  They acknowledged the findings.

Each resident will be given a key to their lockable storage space at move-in and keys will be replaced as needed by ALD, Maintenance Director or designee.

An audit of all occupied RCF apartments will be conducted to ensure all apartments have a lockable storage space for the safekeeping of a resident's small valuable items and funds. Keys will be provided to all residents for each lockable storage space.

ED, ALD, and Maintenance Director were inserviced on the requirement to ensure residents have a locakable storage space and the keys to control access to this space.

ED, ALD or designee audit rooms for lockable storage space with key every new move in for 3 months.

This will be completed at move-in for each resident and keys will be replaced as needed.

Based on observation and interview, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit or used a chemical disinfectant when washing soiled linens and soiled clothing. Findings include, but are not limited to:

Facility laundry rooms were observed on 04/02/24. The following was identified:

* The laundry rooms on the fourth, fifth and sixth floors were used by staff to wash residents' laundry. The washing machines were a residential type with no indicator for the water temperature. The detergent the facility used did not include a disinfecting agent.

* Commercial type washing machines were located in the basement and the detergent the facility used included a disinfecting agent.

During an interview with Staff 4 (Housekeeping Supervisor) on 04/02/24, she indicated staff are to bag up all soiled laundry and bring it to the basement. Housekeeping was responsible for washing the soiled laundry.

During an interview with Staff 15 (Resident Assistant) on 04/02/24 at 9:30 am, she reported that if the item needing washed was only "a little bit" soiled then she washed it in the laundry room located on the resident's floor. Otherwise if the soiled item "is really bad" then she put the soiled item in a plastic bag and delivered it to the basement to be washed.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 2 (Assisted Living Director) on 4/03/34.  She acknowledged the findings.

A laundry detergent with a disinfecting agent was ordered and placed on the washing machines in the laundry room on the fourth, fifth, and sixth floors.

ED, ALD, and Housekeeping Supervisor inserviced on the requirement for soiled laundry to be properly disinfected using a laundry detergent with a disinfecting agent.

The laundry rooms inspected 2x monthly for two months by ALD or designee to ensure laundry detergent contains a disinfecting agent.

The ALD will be responsible to ensure intitial and ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 04/02/24 and 04/03/24 revealed all exit doors to the terrace and fourth floor patio, and exit doors leading to the open air platforms prior to entering the stairwell, failed to have an alarm or other acceptable system to alert staff when residents exited the building.

On 04/03/24, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED) and Staff 3 (Plant Operations Supervisor). They acknowledged the findings.

Devices that alarm or alert staff were ordered and placed on all exit doors to the terrace, fourth floor patio, and exit doors leading to the open air platforms prior to entering the stairwells on floors 4, 5, 6, & 7.

ED, ALD, & Maintenance Director were inserviced on the need to ensure exit doors were equipped with an audible alarm or other acceptable system to alert staff when residents exited the RCF building.

Once operational, the doors will be monitored 3x weekly for two months to ensure proper function and repairs will be made as need is identified.

Maintenance Director, ALD, and ED will ensure installation and repairs are completed.