Print Inspection: 9438

The findings of the re-licensure survey conducted 08/29/23 through 09/01/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities 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 re-visit to the re-licensure survey of 09/01/23, conducted 02/12/24 through 02/13/24, are documented in this report.  It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

A group interview was conducted on 08/30/23 at 11:00 am. Four alert and oriented residents attended the group interview and provided information on services received in the community. Residents expressed concerns in the area of long delays for call light response times.

During individual interviews with Residents 2, 3 and 4, they each confirmed there were concerns regarding long delays for call light response times.

On 08/30/23, call light logs were requested from the facility which documented call response times. Staff 1 (Interim ED) provided documentation of call light logs for 08/01/23 through 08/30/23 for Residents 1, 2, 3, and 4 and two unsampled residents. Review of the call logs revealed the following:

*Resident 1 had 11 calls with answer times which exceeded 20 minutes;

*Resident 2 had 7 calls with answer times which exceeded 20 minutes;

*Resident 3 had 47 calls with answer times which exceeded 20 minutes;

*Resident 4 had 49 calls with answer times which exceeded 20 minutes;

*A unsampled resident had 25 calls with answer times which exceeded 20 minutes; and

*A unsampled resident had 64 calls with answer times which exceeded 20 minutes.

In an interview with Staff 1 on 09/01/23 at 12:20 pm, documented evidence was requested of the facility having addressed resident concerns around long call answer times. Staff 1 stated there was no documented evidence that the facility had addressed the concern.

The need to ensure the facility developed effective methods of responding to and resolving resident complaints was discussed with Staff 1 on 09/01/23. She acknowledged the findings.

OAR 411-054-0025 Facility Admin Policy and Procedure. Review with residents 1,2,3 &4 and then meet with all residents at resident council etc. to educate the system for all grievances.

A grievance log is kept on SharePoint under operations secure. After identifying there is a grievance, the log will be filled out completely and a conversation will be had with resident and family if needed

ED will check Mon-Fri with all manager during standup asking for any concerns that have been brought to them. iAlert the resident call system will be reviewed daily Mon Fri for any call times greater than 5min.

ED will be involved in all grievances unless another is assigned in their absence. ED & HSD to monitor iAlert call times.

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 333-150-000. Findings include, but are not limited to:

On 08/29/23 the facility kitchen was inspected and observed to need cleaning and repair in the following areas:

a. Food spills, splatters, debris, dust, dirt, and black matter was observed on, inside, around or underneath the following:

* Stainless steel upper and lower shelves throughout the kitchen;

* Warewasher;

* Porcelain floor drains throughout the kitchen;

* Ice machine scoop bucket; and

* Right gas oven.

b. The following equipment was in need of repair:

* Observations of the warewasher data plate noted the minimum temperature for the rinse cycle as 180 degrees. On 08/29/23 at 9:52 am the rinse cycle temperature of the warewasher was recorded at 171 degrees. When tested again at 10:13 am, the warewasher rinse cycle temperature was recorded at 168 degrees; On 08/29/23, Staff 1 (Interim ED) arranged for the warewasher to be serviced. On 08/30/23 the facility educated kitchen staff of the hot water booster staff needed to engage to ensure the rinse cycle reached the required temperature. On 08/30/23 at 9:15 am, the warewasher rinse cycle temperature was recorded at 183 degrees; and

* In a 2:17 pm interview on 08/29/23 regarding the buildup of thick black substance in the gas oven on the right, Staff 5 (Dietary Services Manager) stated the oven was not in working order due to irregular distributions of gas caused by a blocked burner tube. The facility was asked to post a sign informing staff the equipment was not in working order as hazard prevention. The sign was observed prior to survey exit.

c. Staff 8 (Dietary Aide), Staff 16 (Dietary Aide) and Staff 18 (Dietary Aide) failed to have documented evidence of a current food handler's card.  

The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules, was discussed with Staff 1 and Staff 5 on 08/29/23. They acknowledged the findings.

C240- OAR 333-150-000 food sanitation. There will be a work party in the kitchen to clean the stainless steel upper and lower shelves throughout the kitchen, Warewasher, porcelain floor drians, ice machine scoop bucket and the right gas oven to be cleaned and repaired. All temps checked daily by DSM. All staff to be review for food handlers card and corrected asap including staff 8,16 &18

This will be a weekly walk thru the kitchen to check for cleanliness and temps. Cleaning check lists and temp logs for all staff to fill out daily. Food handlers cards will be part of the new hire process and tracked by Office manager.

A througho review each week by the ED abd DSM together. Food handlers card reivewed by OM and DSM.

ED and DSM

2. Resident 1 moved into the facility in 10/2019 with diagnoses including type II diabetes.

Resident 1's facility progress notes, dated 06/02/23 through 08/28/23, were reviewed and revealed the resident had a hospital stay due to urinary tract infection and returned to the facility on 06/02/23.

There was no documented evidence the facility gathered data that was relevant to the needs and current condition and updated the evaluation with the documented change of condition.

The need to ensure evaluations were completed with a hospitalization and documented the condition of the resident was discussed with Staff 1 (Interim ED) on 08/30/23 at 12:15 pm. Staff 1 acknowledged the findings.

Based on interview and record review, it was determined the facility failed to conduct an initial evaluation before the resident moved in that included all required information for 1 of 1 sampled resident (#2) and failed to conduct evaluations to determine the resident's physical health status, mental status, and environmental factors to help the individual function at their optimal level for 2 of 4 sampled residents (#s 1 and 2) who required evaluations. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 05/2023 with diagnoses including Parkinson's disease and type II diabetes.

a. Review of the resident's initial evaluation, dated 05/31/23, and interviews with Resident 2 and Staff 2 (LPN/Health Services Director) on 08/30/23 revealed the following:

* the initial evaluation had not been conducted in-person and before the resident moved into the facility;

* the initial evaluation did not include information related to customary routines of eating, bathing and sleeping, neurological implants and current treatments.

b. Review of the clinical record showed the resident was hospitalized on 06/29/23 after experiencing shortness of breath and arm numbness. S/he returned to the facility on 07/03/23 with a new diagnosis of CVA (cerebral vascular accident) and multiple medication changes.

* the record lacked evidence an evaluation was performed following the resident's return to the facility to determine the resident's physical health status, mental status, and any changes needed to the service plan to help the resident function at his/her optimal level.

The need to ensure a thorough evaluation was completed prior to move-in and as needed when a resident experienced changes was discussed with Staff 1 (Interim ED) and Staff 2 on 08/31/23. They acknowledged the findings.

OAR 411-054-0034 Res move in and eval. Resident 1 &2 will have an updated eval and service plan to make sure we are capturning services needed.

No resident will be moved in without a througho eval and SP done completely. This will be monitored daily during smart meeting with Health services for new move ins and COC.

Daily when COC, quarterly and return from HLOC.

HSD & ED

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

1. Resident 1 moved into the facility in 10/2019 with diagnoses including type II diabetes.

Observations of the resident, staff interviews and review of the service plan, dated 07/24/23 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff or was not followed in the following areas:

* Shower status;

* Use of a straw with thickened liquid;

* Use of a gait belt for transfer;

* Use of a wedge while in bed; and

* Weekly housekeeping services.

The need to ensure Resident 1's service plan was reflective of current care needs, provided clear direction to staff and was followed was discussed with Staff 1 (Interim ED) on 08/31/23 at 12:15 pm. She reviewed the service plan and acknowledged the findings.

2. Resident 4 moved into the facility in 01/2017 with diagnoses including paraplegia.

Observations of the resident, resident and staff interviews and review of the service plan, dated 08/03/23, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff or was not followed in the following areas:

* Use of CPAP (continuous positive airway pressure) machine at night;

* Use of a power wheelchair for ambulation; and

* Weekly housekeeping services.

The need to ensure Resident 4's service plan was reflective of current care needs, provided clear direction to staff and was followed was discussed with Staff 1 (Interim ED) on 08/31/23 at 12:15 pm. She reviewed the service plan and acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2022 with diagnoses including Parkinson's disease.

Interviews with care staff and observations of Resident 3 during the survey revealed s/he was dependent on staff for ADL care.

Resident 3's current service plan, dated 06/20/23, was not reflective of the resident's current status and/or being followed in the following areas:

* Bathing;

* Personal hygiene/oral care; and

* Weekly housekeeping services.  

The need to ensure service plans were reflective of the resident's current status and being followed was discussed with Staff 1 (Interim ED) on 08/31/23 at 12:30 pm. The findings were acknowledged.

4. Resident 2 moved into the facility in 05/2023 with diagnoses including Parkinson's disease and type II diabetes.

Observations, resident and staff interviews, and a review of the current service plan, last updated 07/07/23, showed the service plan was not reflective of the resident's current care needs and preferences, did not provide clear direction to staff or was not being followed related to:

* Food/snack preferences, including those related to diabetic status and weight loss goal;

* A description of where the resident experienced pain and effective interventions;

* Assistance required for safe transfers (including use of gait belt);

* Assistance needed with daily hygiene, including shaving;

* Use of CPAP (continuous positive airway pressure) machine at night and cleaning instructions;

* Mobility devices, including use of trapeze; and

* Location, safety precautions and care needed for two neurological implants to control tremors.

The need to ensure Resident 2's service plan was reflective of current care needs and preferences, provided clear direction to staff and the need to ensure the service plan was being followed was discussed with Staff 1 (Interim ED) on 09/01/23 and Staff 2 (LPN/Health Services Director). They acknowledged the findings.

OAR 411-054-0036 Service Plan.

Residents 1,2,3 & 4 will have SP updated to catch any care that may be needed.

Resident centered and COC updated on all service plans to be reflective of residents current needs.

Anytime there is a COC that needs to be addressed immediately & quarterly. Ancillary evals will be evaluated and assesed for all residents as applicable to meet state specific requirements.

RN in community minimum 24 hours a week. HSD and ED to monitor thru daily meetings.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 1 of 1 sampled resident (#3) reviewed for significant changes of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 12/2022 with diagnoses which included Parkinson's disease.

During the entrance conference on 08/29/23, Staff 2 (LPN/Director of Health Services) reported the resident had a recent significant decline in ADL functions and was currently on hospice services.

Review of the clinical record revealed the resident was admitted to hospice on 07/21/23 for decline due to Parkinson's disease.

The decline in ADL functioning and admission to hospice constituted a significant change of condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview by phone on 08/30/23 at 9:15 am, Staff 21 (Regional RN Support) stated she became aware of the significant change of condition on 08/17/23 and that an RN assessment had not been done.

The need to ensure the facility RN completed an assessment timely when a resident experienced a significant change of condition was discussed with Staff 1 (Interim ED) on 08/31/23 at 12:30 pm. She acknowledged the findings.

OAR 411-054-0045 Resident Health Services. Resident 3 will be reviewed for COC and update SP.

COC to be reported to RN who will assess and coordinate sig COC per state policy.

Will review any COC during the daily smart meeting where we reivew all thing health services.

HSD & ED

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 2) who received 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.

During the acuity interview on 08/29/23, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2's MARs, reviewed from 08/01/23 through 08/30/23, revealed insulin had been given by Staff 4 (MT), Staff 9 (MT), Staff 10 (MT), Staff 12 (MT), Staff 15 (MT) and Staff 22 (MT) on multiple occasions.

a. Review of Resident 2's delegation documentation on 08/30/23 revealed there was no documented delegation completed for Staff 10, Staff 12, Staff 15 and Staff 22.

In an interview on 08/30/23 at 4:00 pm, Staff 1 (Interim ED) said the facility used a delegation consultant team for the delegation and would check with the delegation consultant team for any additional documentation.

On 08/31/23 at 12:15 pm, Staff 1 confirmed there was no documented delegation completed for Staff 10, Staff 12, Staff 15 and Staff 22. Staff 1 was informed that Staff 10, Staff 12, Staff 15 and Staff 22 should not administer insulin to Resident 2 until staff were delegated.

b. The most recent periodic inspection, supervision and re-evaluation of the delegation of insulin for Staff 4 and Staff 9, completed 06/02/23 and 06/06/23 was reviewed. The initial re-evaluation was not completed within 60 days of the initial delegation for Staff 4 and Staff 9.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 on 08/31/23 at 12:15 pm. She acknowledged the findings.

OAR 411-054-0045 Delegation & Teaching. Res 2, staff 10,12,15&22 all need to be delegated by the hired company ANDS. Staff 4 & 9 needed re-evaluation but was not completed within 60 days of initial delegation. All staff need delegated in accordance with state laws. ED & HSD to communicate with delegation company ANDS when there is a change in staff.

ANDS will monitor thru communication w/ HSD & ED for new hires and changes in med techs. A minimum of weekly communication to delegating nurse.

OM to send all new hires to Delegating service to support monitoring & corrdination & folowup. ED & HSD can monitor daily with Smart meeting.

Based on observation, interview, and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented, communicated to staff, and the service plan updated for 1 of 1 sampled resident (# 2) who was receiving home health services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2023 with diagnoses including Parkinson's disease and type II diabetes. Resident 2 was receiving home health services which included physical and occupational therapy.

The resident's home health services notes, progress notes, current service plan, and service plan addendums were reviewed from 05/31/23 through 08/29/23. Home health PT notes documented the following:

* 06/27/23: "encourage [resident] to call for all transfers, ensure foot plates on power w/c [wheelchair] are folded up before transfers.";

* 07/17/23: "use of gait belt with all transfers.";

* 08/04/23: "escorted walk from lunch daily, use T-wheeled walker, gait belt."; and

* 08/12/23: "SBA [stand by assist] for toilet transfers, power chair only for mobility."  

During an interview on 08/30/23, Resident 2 stated staff use of a gait belt during transfers was "inconsistent" and s/he had not been provided any assistance to walk from the dining room to his/her room. On 08/31/23, Staff 2 (LPN/Health Services Director) confirmed there was no documentation showing the home health recommendations had been reviewed and communicated to direct care staff.

The need to ensure outside provider recommendations and instructions were reviewed, communicated with staff and implemented was discussed with Staff 1 (Interim ED) and Staff 2 on 08/31/23. They acknowledged the findings.

OAR 411-054-0045 Resident Health services. Res 2 Outside agency to place notes in box outside of the nurrses office. Nurse to summarize notes & identy current needs to staff.

Minumum weekly coord of care between nursing & 3rd party providers then follow up by nursing. SP and spas to be refelective of recommendation.

Weekly by nurse, daily during smart meetings

HSD, ED & Med tech

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care for 1 of 2 sampled residents (# 1) whose care was observed. Findings include but are not limited to:

Observations were made during the survey to determine adherence to universal precautions for infection control.

On 08/31/23, approximately 10:30 am, the surveyor obtained permission and observed Staff 9 (MT) provide incontinence care to Resident 1.

During the observation, Staff 9 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 1's bottom area. Staff 9 applied cream treatment to Resident 1 and touched the resident's shirt, pants and power wheelchair while wearing the same soiled gloves. When Staff 9 was finished providing incontinent care, Staff 9 removed the gloves but did not perform hand hygiene.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Interim ED) on 08/31/23 at 12:15 pm. She acknowledged the findings.

OAR 411-054-0050 Infection prevention & control. Resident 1 & staff 9, we will train staff with a mandatory inservice in regards to infection control skills training. OM will also take the Infection control class to become Infection control specialist. Until then Regional nurse is the infection control specialist. OM to monitor all staff for infection control skills and education.

Upon hire and monthly via spead sheet.

ED OM HSD

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:

The facility failed to ensure a safe medication and treatment system and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 282: RN Delegation and Teaching;

C 310: Systems: Medication Administration; and

C 330: Systems: Psychotropic Medications.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was reviewed with Staff 1 (Interim ED) and Staff 2 (LPN/Health Services Director) on 09/01/23. They acknowledged the findings.

OAR 411-054-0055 Medication & Treatment. RN delegation to be corrected thru consistant communication with outside agency ANDS. System medications and administration including Psychotropic meds with be overseen by RN on site.

RN on site minimum 24 hrs a week to watch teach and train staff on administration of medication.

Daily during smart meetings, regularly during the course of the day watching med pass. With each new employee hired.

HSD ED

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

1. Resident 1 was admitted to the facility in 10/2019 with a diagnosis of type II diabetes.

A review of the Resident 1's 08/01/23 through 08/30/23 MAR, progress notes from 08/01/23 through 08/28/23 and physician's orders revealed the following:

a. Glycopyrrolate (for oral secretions) and morphine (for pain or shortness of breath) had physician ordered dosages and medication bottle labels that matched. However, the dosage was transcribed incorrectly onto the MAR.

b. Physician order for calmoseptine (for rash) was to be applied PRN four times daily, however the MAR showed the medication was administered four times daily and PRN every 24 hours.

c. Physician orders for nystatin (for rash) were for application routinely twice a day and an order for application PRN twice a day. The order to apply PRN twice a day was missing from the MAR.

d. Physician order for a diet consistency of  "thickened liquids to nectar thick consistency" was ordered. The MAR stated "mix to nectar thick consistency as needed."

e. Macrobid a brand name for an antibiotic, has a generic name, Nitrofurantoin. The same medication, with two different names, was documented on the MAR on 08/04/23 directing staff to administer one capsule two times per day.  The MAR noted both Macrobid and Nitrofurantoin were administered at 9:00 am and at 6:00 pm on 08/04/23.  

Progress notes, dated 08/04/23 at 07:34 am revealed the resident received medication from two prescriber's for the antibiotics. Staff 10 (MT) called the pharmacy and was advised to use the Macrobid 100mg and return the Nitrofurantoin Macrocrystal.  

In an interview on 08/31, Staff 2 (LPN/Health Services Director) stated she knew of the incident and the instruction was to remove the Nitrofurantoin Macrocrystal medication from the cart.

f. A physician order noted benzocaine-menthol throat lozenge was to be administered every three hours while awake.

On 08/05 staff began to initial "MN" indicating that the medication was not given. Staff initialed the MAR three times between 08/06-08/08/23 indicating the medication had been administered. Staff 2 reported the resident ran out of the medication and was notified by the pharmacy on 08/10/23 that this medication was not covered by insurance. The medication was documented as administered even though the medication was not available in the facility.  

g. Documentation on the MAR noted Resident 1 was "supervised self administration" for 12 different medications and treatments. Staff 2 acknowledged the resident did not self administer any medications or treatments.

h. The MAR lacked clear instructions for staff regarding the sequential order of use for the following PRN medications:

* Calcium carbonate and milk of magnesia were prescribed for heartburn;

* Lorazepam and haloperidol were prescribed for anxiety;

* Guaifenesin-DM and benzocaine menthol were prescribed for cough; and

* Calmoseptine, nystatin and ketoconazole cream were prescribed for rash.

The need to ensure MARs were accurate and contained medication-specific instructions was reviewed with Staff 2 on 08/31/23. She acknowledged the findings. No further information was provided.

2. Resident 2 moved into the facility in 05/2023 with diagnoses including Parkinson's disease and type II diabetes.

Resident 2's physician's orders and 08/01/23 through 08/29/23 MAR were reviewed and the following was identified:

a. Physician's orders were reviewed and showed the following:

* Acetaminophen 500 mg every 12 hours as needed for pain and hydrocodone-acetaminophen 10-325 mg every eight hours as needed for pain were reviewed. The MAR lacked parameters instructing staff on which medication to use first; and

* A physician's order to test blood glucose two times a day was reviewed. There were no parameters instructing staff when to contact the nurse or prescriber when blood glucose readings were high or low.

b. The MAR had multiple blank spaces or were missing the initials of staff that administered multiple medications. Staff 2 (LPN/Health Services Director) verified the medications had been administered, but were not marked as "administered" on the MAR.

c. The narcotics tracking log for Resident 2 was reviewed on 08/31/23. The log book showed a dose of hydrocodone/APAP was administered to the resident on 08/22/23 at 6:38 pm. The medication was not documented as administered on the MAR. On 08/31/23, Staff 2 verified a previous investigation by the facility showed Resident 2 had not been administered the 6:38 pm dose and the documentation was inaccurate.

d. Multiple medications on the MAR were coded "MN" (medication not given) or "9" (see progress note) between 08/09/23 and 08/14/23. The record did not contain any additional documentation as to why the medications were not given.

The need to ensure MARs were accurate, included resident specific parameters and instructions for PRN medications and included the initials of the person administering the medications was reviewed with Staff 1 (Interim ED) and Staff 2 on 09/01/23. They acknowledged the findings.

OAR 411-054-0055 Medication administration.Res 1 & 2. Med cart audit to be completed along with MAR & MD reviews. Staff 2 & 10 to be retrained on medication administration.

90 day orders to be resent to PCP/ NP 9/2023 Med/ treatment indications to be audited & updated by nursing. Parameters to be audited for CBG & PRN medications. Retraining on reporting meds not available.

Narc book/admin audit to be completed weekly by HS leadership.

ED, HSD

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 1 of 1 sampled resident (#1) who was prescribed PRN psychotropic medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2019 with diagnoses including type II diabetes.

Review of Resident 1's 08/01/23 through 08/30/23 MAR and current physician orders revealed PRN psychotropic orders for the following:

* Lorazepam 0.5 mg, one tablet every six hours as needed for anxiety or agitation; and

* Haloperidol lactate 2 mg/ml, 0.25ml every two hours as needed for anxiety/agitation or nausea/vomiting.

The facility had not administered either of the medications to the resident since the orders started on 08/17/23.

The MARs lacked resident specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were to be attempted prior to administration of the medication.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and non-drug interventions were developed prior to administration of the medication was discussed with Staff 2 (LPN/Health Services Director) on 08/31/23. She acknowledged the findings.

OAR 411-054-0055 Psychotropic Medication. Res 1, nurse will review resident MAR for specific parameters to deliver psychotropic meds.

Nursing to review in MARS all current & on going psychotropic meds, monitoring, coordination & intervention review to support indications & system management. Parameters to be entered into MAR and all staff retrained.

Every 90 days or new order

HSD

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

1. Resident 1 moved into the facility in 10/2019 with diagnoses including type II diabetes.

The resident's service plan, temporary service plans, progress notes dated 06/02/23 through 08/28/23, RN assessment dated 08/17/23 and the ABST report was reviewed and revealed the following:

* 06/02/23: Resident 1 returned to the facility after hospitalization for urinary tract infection;

* 08/12/23: The resident was sent to the hospital and returned to the facility on 08/16/23 with increased monitoring and assistance; and

* 08/18/23: Admitted to hospice services.

The ABST report for Resident 1 failed to reflect his/her current care needs and level of assistance in the following areas:

* time spent on bathing;

* time spent on transferring in and out of bed or a chair;

* time spent on ambulation, escorting to and from meals or activities;

* time spent on supervising, cueing or supporting while eating; and

* time spent on completing housekeeping and laundry tasks.

The need to ensure the ABST tool was reviewed following a resident's significant change of condition and updated was discussed with Staff 1 (Interim ED) on 08/31/23. She acknowledged the findings.

3. A review of the ABST being used by the facility and an interview with Staff 1 (Interim ED) and Staff 21 (Regional RN Support) via phone on 08/30/23 at 9:15 am  revealed an audit of the ABST had been completed 07/2023, however, not all resident information had been updated quarterly or with significant changes of condition.

The need to ensure all residents were updated in the ABST tool, at least quarterly, was reviewed with Staff 1 on 08/30/23 and 09/01/23. No additional information was provided.

2. Resident 2 moved into the facility in 05/2023 with diagnoses including Parkinson's disease and type II diabetes.

An interview was conducted with Resident 2 on 08/30/23 to discuss care needs and services. The resident's current service plan, evaluation completed 07/01/23, progress notes dated 05/31/23 through 08/28/23, and ABST report, last updated 07/26/23 was reviewed and revealed the following:

The ABST report for Resident 2 failed to reflect his/her current care needs and level of assistance in the following areas including:

* time spent on personal hygiene, such as shaving;

* time spent on grooming; and

* time spent on safety checks.

The need to ensure the ABST tool addressed the amount of staff time needed to provide care to the resident was discussed with Staff 1 (Interim ED) on 09/01/23. She acknowledged the findings.

OAR 411-054-0037 ABST, Res 1 & 2 Nursing to review SP /ABST review immediately for changes of SP for accuracy.

With each COC will update tool. Nurse to review all residents.

COC, Quarterly, Upon move in & 30 day from move in.

HSD ED

Based on interview and record review, it was determined the facility failed to ensure all required pre-service orientation and training had been completed for 3 of 3 newly-hired staff (#s 6, 13 and 20) whose pre-service training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/23 and the following was identified:

a. Training records for Staff 20 (MT), hired on 07/12/23, Staff  13 (Personal Care Attendant), hired on 01/20/23, and Staff 6 (Personal Care Attendant), hired on 04/20/23, lacked documented evidence of Department approved infectious disease prevention training prior to beginning job duties.

b. Staff 6 and Staff 13 lacked documented evidence of dementia care training prior to beginning job duties including:

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

* Techniques for understanding, communication and responses to distressful behavioral symptoms;

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

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

The requirement to complete pre-service orientation and training prior to providing care to residents was discussed with Staff 1 (Interim ED) on 08/29/23. She acknowledged the findings.

OAR 411-054-0070 Staffing requirements & training. Preservice orientation for all employees. Staff #6, 13 & 20. Will immediately receive training for infectious disease prevention and dementia care.

All new EE to have preservice orientation before working the floor. Office Manager to use spead sheet and collect all certs.

With all new employees upon hire and Montly audit

ED and OM will moniotor new EE and exciting EE on a monthy basis.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled, newly-hired, direct care staff (#s 6, 13 and 20) demonstrated competencies in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 08/29/23 and the following was revealed:

Staff 20 (MT) hired on 07/12/23, Staff 13 (Personal Care Attendant), hired on 01/20/23 and Staff 6 (Personal Care Attendant) hired on 04/20/23 failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First aid and abdominal thrust training.

In addition, Staff 20 failed to have documented evidence appropriate facility staff observed and evaluated her ability to perform safe medication and treatment administration unsupervised.

In an interview on 08/29/23, Staff 2 (LPN/Health Services Director) confirmed she had observed Staff 20 demonstrate competency with medication and treatment administration prior to working with residents, but was unable to locate the documentation. The competency documentation was provided, following request, on 08/31/23.

The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working independently with residents was discussed with Staff 1 (Interim ED) on 08/29/23. She acknowledged the findings.

OAR 411-054-0070 Training within 30 days. Staff 20 will have documentation that she can perform safe medication and treatment administration. All staff need to have documented evidence of demonstrated competency in all assigned duties prior to working with independently with residents. All staff training records will be recorded by nursing for completion and placed in file.

Upon hire and monthly for competancy check list.

HSD ED OM

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 2 of 2 long term staff (#s 7 and 9) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 1 (Interim ED) on 08/29/23. Staff 9 (MT) hired on 12/02/18 and Staff 7 (Personal Care Attendant), hired on 06/05/20, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire dates, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training,

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 on 08/29/23. She acknowledged the findings.

OAR 411-054-0070 Annual inservice for all staff.Staff 7 &9 will work with Health care academy to complete monthy training to achieve the required 12 hours each year.

Upon hire & then reviewed montly for annual education, certificates placed in file.

monthly on spread sheet

ED & OM

Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills 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 02/2023 through 08/2023 were reviewed with Staff 3 (Maintenance Director) on 08/30/23. The facility lacked documented evidence fire drills included the following components:

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; 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 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 (Interim ED) and Staff 3 on 08/29/23. They acknowledged the findings.

OAR 411-054-0090 Fire & Life safety. Maint Director to be reeducated on fire drills including escape route used, Problems encountered relating to residents and number or occupants evacuated. He will also be retrained in fire and life safety instruction for everyother month alternating the fire drills.

ED to monitor montly thru TELS system and or binder.

Weekly during 1 on 1 and Monthly

ED and Maint Director

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

The facility was toured on 08/29/23 at 10:30 am. The following areas were observed to need cleaning and/or repair:

* First floor corridors had an unpleasant pervasive odor throughout the survey;

* First floor resident laundry room light fixture was missing a cover and a ceiling tile had a large crack in it;

* First floor public bathroom and unit 128 doors and doorframes had chipped paint and gouges;

* Carpet on the first floor near the public restroom, inside the elevator, in other first floor common areas and inside unit 113 was worn in areas and had black and brown stains; and

* Wood cabinet to the right of the kitchen entrance door had a large gouge on the right of the cabinet making the area uncleanable.

The surveyor toured the environment with Staff 3 (Maintenance Director) on 08/30/23. The need to ensure the facility was clean and in good repair was discussed with Staff 1 (Interim ED) on 08/31/23. She acknowledged the findings.

OAR 411-054-0300 General building. Maint director to find odor in common areas. Replace light fixture in 1st floor resident laundry room and ceiling tile. 1st floor public restroom and unit 128 doors and frames had chipped paint and gouges. Clean carpets near public restroom 1st floor and inside Rm 113. Wood cabinets, right of kitchen etrance door had large gouge will be repair.

Maint director to Walk the floor on a daily basis to identify issues. Work with TELS system to complete orders. Weekly review with ED during 1on1 meeting.

Maint Director and ED