Print Inspection: C9BO

The findings of the re-licensure survey, conducted 04/03/23 through 04/05/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 04/05/23, conducted 09/19/23 through 09/20/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 04/05/23, conducted on 12/13/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

A tour of the facility conducted on 04/03/23 identified the following required posting were not in place:

* The name of the administrator or designee in charge posted by shift; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (ED) on 04/03/23. She acknowledged the findings.

C152

OAR 411-054-0025 Facility Administration: Required Postings

1.Actions to be taken to correct the rule violation include:

a.The most recent survey, plan of correction and re-survey will be posted and accessible to view, in the common area, near the front desk.

b.Facility will update and post designee in charge, in the common area, near the front desk.

2.To ensure the system will be corrected so this violation does not happen again;  

a.The facility administrator or designee will be trained on the importance of required postings and will be given a copy of the OARs related to required posting.

b.The facility administrator or designee will be trained on the importance of having updated, accurate postings related to the designee in charge, and will be given a copy of the OARs related to required postings.

3.Facility required posting systems will be audited at least once

monthly by IDT during quality improvement meetings and required postings will be reviewed weekly to ensure the most accurate and up to date information is posted.

4.The facility administrator or designee will be responsible for

ensuring corrections are made and required postings are monitored.  

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required elements, quarterly evaluations were completed timely, and resident evaluations were reviewed and updated with significant changes in condition, for 3 of 3 sampled residents (#s 1, 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 and was receiving hospice services.

Resident 1's most current evaluation was completed 10/22/22. There was no documented evidence of quarterly evaluations being completed.

Resident 1 began hospice services for end of life care on 03/14/23.  There was no documented evidence Resident 1's evaluation had been reviewed and updated with this significant change in condition.

2. Resident 2 was admitted to the facility in 02/2023.

The move-in evaluation lacked the following elements:

* Customary routines, such as those related to sleeping, eating, and bathing;

* Interests, hobbies, social and leisure activities;

* Personality, including how the person copes with change or challenging situations;

* History of dehydration;

* Recent losses; and

* Environmental factors that impact the resident's behavior, including, but not limited to: noise, lighting and room temperature.

3. Resident 3 was admitted to the facility in 03/2023.

The move-in evaluation lacked the following elements:

* Customary routines, such as those related to sleeping, eating, and bathing;

* Interests, hobbies, social and leisure activities;

* Personality, including how the person copes with change or challenging situations;

* History of dehydration;

* Recent losses; and

* Environmental factors that impact the resident's behavior, including, but not limited to: noise, lighting and room temperature.

The need to ensure new move-in evaluations contained all required elements and evaluations were reviewed quarterly and with significant changes in condition was discussed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/03/23 and 04/04/23. They acknowledged the findings.

C252

OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation

1. Actions to be taken to correct the rule violation include:

a.Resident #1 evaulation will be updated to reflect significant change of condition, end of life care.

b.Resident #2 the following innaccuracies and incomplete areas on the evaluation will be corrected;. Customary routines, such as those related to sleeping, eating, and bathing; * Interests, hobbies, social and leisure activities; Personality, including how the person copes with change or challenging situations; History of dehydration; Recent losses; and * Environmental factors that impact the resident's behavior, including, but not limited to: noise, lighting and room temperature

c.Resident #3 the following innaccuracies and incomplete areas on the evaluation will be corrected; Customary routines, such as those related to sleeping, eating, and bathing; * Interests, hobbies, social and leisure activities; Personality, including how the person copes with change or challenging situations; History of dehydration; Recent losses; and Environmental factors that impact the resident's behavior, including, but not limited to: noise, lighting and room temperature.

2.To ensure the system will be corrected so this violation will not happen again; a complete audit of 100% of current evaluations will be conducted. Additionally,going forward all evaluations including all required factors will be completed per company policy and Oregon Administrative Rule prior to move-in, updated within 30 days, quarterly thereafter and with any signifcant change of condition. The document should be signed to indicate who completed the evaluation.

3.The area will need to be reviewed and audited on a quarterly basis via continuous quality improvement system. Completion and accuracy of evaluations will be reviewed in daily clinical stand-up meeting prior to each new move-in to ensure all components are reflective and all areas are complete with appropriate information.

4.The Adminsitrator, Licensed Nurse or designee will be responsible to ensure the system has been corrected and the system is monitored.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current health status, care needs, provided clear direction to staff, and were reviewed and updated quarterly and following significant changes in condition for 2 of 3 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 and was receiving hospice services.

Staff identified that Resident 1 required assistance with bathing and medications, including a breathing treatment, and was recently admitted to hospice. Staff indicated hospice was providing assistance with bathing.

Resident 1 was observed to ambulate independently using a four wheeled walker. A nebulizer machine was observed in Resident 1's room.

Resident 1's current service plan was dated 10/04/22. There was no documented evidence the service plan had been reviewed or updated quarterly.

Resident 1 was admitted to hospice for end of life care on 03/14/23. There was no documented evidence Resident 1's service plan was reviewed and updated with this significant change in condition.

Resident 1's service plan was not reflective of, and lacked direction to staff for:

* Hospice services including bathing assistance; and

* The use of a nebulizer for breathing treatments.

Resident 1' service pan indicated s/he had a dog and included interventions for the dog's behavior. Resident 1 did not have a dog.

2. Resident 3 was admitted to the facility in 02/2023 with diagnoses including quadriplegia.

Resident 3 was observed to utilize an electric wheelchair for mobility and had a urinary catheter in place.

Staff indicated Resident 3 required full assistance with all care needs including assistance with catheter care.

Resident 3's current service plan dated 03/11/20, lacked clear direction for staff related to the cleaning and care of the catheter.

The need to ensure service plans were reflective,  reviewed and updated with changes in condition, and provided clear directions for care staff was reviewed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/03/23 and 04/05/23. They acknowledged the findings.

C260

OAR 411-054-0036 (1-4) Service Plan: General

1.Actions to be taken to correct the rule violation include:

a.Resident #1 care plan will be updated to reflect the evaluation, person centered with individual preferences and care needs. To address all changes including but not limited to; Hospice services including bathing assistance; and the use of a nebulizer for breathing treatments, ambulation, and devices. Pet, and pet care.

b. Resident #3 care plan will be updated to reflect the evaluation, person centered with individual preferences and care needs. To address all changes including but not limited to; diagnosis, continence & toileting, mobility and devices used for mobility and ambulation, directions for catheter care and cleaning.

c.A complete audit of all service plans to be conducted to ensure all areas required within OAR 411-054-0036 are met.

2.To ensure the system will be corrected so this violation does not happen again; service plans will be reviewed and updated with any acute or significant change of condition, as well as with pre-scheduled updates (initial, 30 day and ongoing quarterly updates) to reflect the residents' current status per Oregon State Rule. Clinical services and Administrator participate with this process to ensure accuracy and personalization, as well as the resident and / or their POA / Representative.

3.At time of move in, 30-day review, quarterly and as needed if a change of condition occurs.

4.The administrator, Licensed Nurse or designee will be responsible to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for Residents 1, 2, and 3 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team.

On 04/05/23, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED). She acknowledged the findings.

C262

OAR 411-054-0036 (5) Service Plan: Service Planning Team

1.Actions to be taken to correct the rule violation include: Resident #1, #2, #3 service plans will be updated with evidence that the resident and / or, the resident's legal representative / person of resident's choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services participates.

2.To ensure the system will be corrected so this violation will not happen again; a complete audit of 100% of the service plans will be conducted. Going forward the service plans will be developed by a service planning team. Monthly service plan review schedule will be set up to ensure timely reviews take place consistently. An invitation will be extended to family / person of resident's choice to attend the service plan meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to service plan.

3.The area will need to be evaluated at resident move in, 30-day review and quarterly update and / or as needed if significant change of condition occurs.

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

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 2, 4, and 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

The most recent service plans for Residents 2, 4, and 5 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team.

On 09/19/23 and 09/20/23, the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED). She acknowledged the findings.

1. Actions to be taken: sampled resident service plans will be updated with evidence that the resident and/or, the resident's legal representative/person of resident's choice, the facility Administrator or designee, and at least one other staff person familiar with their provided services participates.

2. To ensure the system will be corrected so this violation will not happen again; a complete audit of 100% of the service plans will be conducted. Going forward the service plans will be developed by a service planning team. Monthly service plan review schedule will be set up to ensure timely reviews take place consistently. An invitation will be extended to family/person of resident's choice to attend the service plan meeting. All those in attendance will review and sign the service plan. Those not able to attend will be sent a copy of the service plan for review and signature. Signature page will then be attached to service plan.

3.The area will need to be evaluated at resident move in, 30-day review and quarterly update and / or as needed if significant change of condition occurs.

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

Based on observation, interview, and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition, including resident specific instructions communicated to staff on each shift, weekly progress notes until the condition resolved, and updates to the service plan for 3 of 3 sampled residents (#s 1, 2 and 3) who had short term and significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 and was receiving hospice services for end of life care.

The resident's 10/04/22 service plan, 01/03/23 through 03/30/23 Progress Notes, and physicians orders were reviewed. The resident experienced changes without documented evaluation, monitoring, and update to the service plan in the following areas:

* Medication changes; and

* New terminal diagnoses and admission to hospice services.

2. Resident 2 was admitted to the facility in 02/2023 with diagnoses including diabetes.

Staff identified Resident 2 as requiring assistance with transfers, dressing, toileting, and bathing. Staff reported Resident 2 had been hospitalized multiple times and had recently started receiving insulin injections.

Resident 2 was observed to be escorted in a manual wheelchair.

The resident's 02/27/23 service plan, 03/04/23 through 03/31/23 Progress Notes, and physicians orders were reviewed. The resident experienced changes without documented evaluation, monitoring, and update to the service plan in the following areas:

* Electric wheelchair;

* Medication changes;

* Urinary tract infections;

* Episodes of vomiting;

* High blood sugars;

* Hospitalizations; and

* New physicians order for routine and sliding scale insulin.

3. Resident 3 was admitted to the facility in 03/2023 with diagnoses including quadriplegia.

Resident 3 was observed to utilize an electric wheelchair for mobility and had a urinary catheter.

The resident's 03/11/23 service plan, 03/04/23 through 04/03/23 Progress Notes, and physicians orders were reviewed. The resident experienced changes without documented evaluation and monitoring in the following areas:

* Medication changes;

* Urinary tract infections;

* Catheter leaking;

* Emergency department visits; and

* Wound to buttocks.

The need to ensure changes in residents' condition were evaluated, assessed by the RN if significant, interventions developed and communicated to staff, and short term changes monitored until resolved was reviewed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/03/23, 04/04/23, and 04/05/23. They acknowledged the findings.

C270

OAR 411-054-0040 Change of Condition and Monitoring

1.Actions to be taken to correct the rule violation include the following:

a.Resident #1 - a comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, resident change in medication, terminal diagnosis, and admission to hospice services.

b.Resident #2 a comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, hospitalizations, delegations; sliding scale insulin, changes in medications, urinary tract infections, episodes of vomiting and ambulation/mobility and devices used.

c.Resident #3- a comprehensive nursing assessment and appropriate follow up will be completed related to but not limited to, electric wheelchair, ambulation & mobility; toileting/continence and catheter care including how to use and clean, urinary tract infections, medication changes, emergency room visits and skin/wound care.

2.To ensure the system will be corrected so this violation will not happen again, a 24-hour communication system will be in place to include:

a.Shift to Shift Communication Log

b.Alert Charting Log / Audit Log

c.Significant Change of Condition Log

d. Weekly Skin Monitoring Log

e.Staff will start short term monitoring / communication system for any resident identified to have an acute change of condition such as UTI, missed medication, return from the hospital, or fall for example.

1.When a change of condition is identified, staff add the resident name to the alert log to ensure they monitor resident and identify when to report concerns to nursing or physician.

2.The staff will be aware of what to report to the nurse / physician per the temporary service plan (TSP) that has been put in place, which correlates with the resident change of condition. The TSP has specific directions for staff including what to look for, interventions to put in place, signs and symptoms to report and staff signature lines to sign once they have read and understood the TSP.

3.Staff should monitor resident status until resident condition resolves, and they are back to their baseline, 24- hour book / process will be reviewed daily during clinical review as a means of identification of potential significant change that needs to be assessed by the RN.

3.The area needed correction will be evaluated daily during

     stand up with 24-hour audit system compliance.

     Community will also complete Monthly Continuous Quality

     Improvement audit to ensure clinical systems follow

     company policy and Oregon Administrative Rule.

4.The Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored.

Based on interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes in condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 and was receiving hospice services for end of life care.

Staff reported Resident 1 was recently diagnoses with a terminal diagnoses and began hospice services for end of life care.

Review of Resident 1's progress notes indicated hospice services were started on 03/14/23.

There was no documented evidence of a RN assessment of this significant change in condition.  Resident 1's current service plan was dated 10/04/22 and lacked any updates to reflect the change or services provided by hospice.

2. Resident 2 was admitted to the facility in 02/2023 with diagnoses including diabetes.

Staff reported Resident 2 had been hospitalized multiple times and had a new order for routine and sliding scale insulin.

There was no documented evidence of a RN assessment of this significant change in condition.

The need to ensure significant changes in condition were assessed by the RN and resident services plans were reviewed an updated with changes was discussed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/03/23, 04/04/23, and 04/05/23. They acknowledged the findings.

C280

OAR 411-054-0045 Resident Health Services

1.Actions to be taken to correct the rule violation include:

a.Resident #1 will have a comprehensive significant change of condition assessment specific to potential increase in ADL care related to overall decline in health condition and admission to end of life care with hospice services. The care plan will be updated to reflect current interventions / needs of the resident.

b.Resident #2 will have a comprehensive significant change of condition assessment specific to multiple hospitalizations, and diabetic care including insulin administration and delegations. The care plan will be updated to reflect current interventions / needs of the resident.

2.This system will be corrected so this violation does not happen again by the following measures:

a.All resident changes are reported and documented via the 24-hour reporting system.

b.The community nurse will assess the resident and condition change in a timely manner to determine any need for further monitoring.

c.A comprehensive assessment should be completed by RN if the change is significant for the purpose of developing, implementing and evaluating a plan of care.

d.RN will utilize a significant change of condition log to direct who requires a weekly nursing assessment until the resident is back at their baseline health status, or a new baseline can be established. A significant change of condition includes, but is not limited to return from hospital, falls, admission to or change of status with hospice, pain and decline in health status.

3.The area needing correction will be evaluated on a daily basis. Changes of condition are reviewed through the 24-hour process audit in daily standup meeting to provide oversight and follow up by RN when needed.

4.The Administrator and Registered Nurse will be responsible for ensuring the system has been corrected and is monitored.

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 04/03/23, Resident 2 was identified to be administered insulin injections by non-licensed staff.

There was no documented evidence of a nursing assessment of Resident 2 to determine the residents stability and predictability, including rationale the task could be safely delegated. There was no noted frequency, including rationale, for reassessment of the resident .

Resident 2's MARs, reviewed from 03/01/23 through 04/03/23, revealed routine and sliding scale insulin had been given by Staff 5, 7, 11, and 12 (MAs) on multiple occasions using an insulin pen.

The initial delegations for the staff were completed between 03/08/23 and 03/13/23, and lacked documentation in the following areas:

* The skills, ability, and willingness of the unlicensed person; and

* How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver.

Additionally, Staff 2 (RN Wellness Director) scheduled the re-evaluation of staff for 90 days, not within 60 days of the initial delegation as required.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 on 04/04/23. She acknowledged the findings.

C282

OAR 411-054-0045 RN Delegation and Teaching

1.Actions to be taken to correct the rule violation include:

a.A comprehensive delegation audit will be completed to ensure delegation and supervision of special tasks of nursing care are being done consistently in accordance with OSBN Administrative Rules.

b.Resident #2 and 100% of delegated staff will be assessed to ensure stability and predictability,

c.Delegation log to be updated and a copy kept in the medication room for all med techs to share accountability with schedule / plan to re-delegate.

2.This system will be corrected so this violation does not happen again by the community RN having documented evidence of completing the RN Delegation in Community Based Care self-study course, schedule and complete the exam and print the certificate for CEU to be kept in delegation binder.

3.The area needing correction will be evaluated on a monthly basis, utilizing the delegation audit tool and updating delegation log monthly and as needed.

4.Delegating RN and Administrator are responsible to see that the corrections are completed and monitored in accordance with OAR 411-054-0045

Based on observation, 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 2 sampled residents (#1) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was admitted in 06/2021 and was receiving hospice services.

Resident 1 had an order for Lorazepam 0.5 mg one tablet as need for mild agitation, anxiety, mild nausea, and dyspnea.

Resident 1's Controlled Substance Disposition Logs, medication bubble packs, and MARs, reviewed from 03/01/23 to 04/04/23, revealed two occasions when staff signed on the drug disposition log the medication was given and the medications were punched from the bubble pack. However, the MAR lacked documentation the resident received the medication.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN) on 04/04/23. They acknowledged the discrepancies.

C302

OAR 411-054-0055 (1) (e.) Systems: Tracking Controlled Substances:

1.Actions to be taken to correct this violation includes,

              a. Facility will correct hole(s) in the MAR

                  for resident #1, who received PRN hospice comfort

                  medication per the narcotic log.

2.This system will be corrected to eliminate further violations,

as follows:

              a. Facility RCC will complete a narcotic

                  audit to ensure appropriate documentation

                  of PRN & Scheduled Narcotics, ensure

                  consistency between narcotic book and

                  MAR, to ensure all narcotics are destroyed

                  per policy, and to identify any trends in

                  narcotic administration.

3.     This system will be evaluated as follows:

              a. Facility RCC will complete a narcotic

                  audit at least once weekly,

              b. Facility RCC will bring all narcotic audits to

                  once monthly quality improvement meetings,

            c. Facility Administrator will review all narcotic

                audits at least once monthly to ensure

                completion.

4.       Facility Administrator and Facility RCC will ensure

         on-going compliance.

Based on observation, 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 2 sampled residents (#5) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted in 05/2018 and was receiving hospice services.

Resident 5's 09/01/23 through 09/19/23 MARs were reviewed.

Resident 5 had an order for liquid Morphine solution 5 mg via oral syringe as needed for severe pain.

Resident 5's Controlled Substance Disposition Logs, pre-filled Morphine syringes, and MARs revealed five occasions when staff signed on the drug disposition log the medication was given and the syringes were gone. However, the MAR lacked documentation the resident received the medication.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) on 09/20/23. She acknowledged the discrepancies.

1.Actions to be taken to correct this violation includes,

a. Facility will correct hole(s) in the MAR for sampled resident, as possible.

2.This system will be corrected to eliminate further violations by:

a. Facility RCC will complete a narcotic audit to ensure appropriate documentation of PRN & Scheduled Narcotics, ensure consistency between narcotic book and MAR, to ensure all narcotics are destroyed per policy, and to identify any trends in narcotic administration.

3. This system will be evaluated as follows:

a. Facility RCC will complete a narcotic audit at least once weekly,

b. Facility RCC will bring all narcotic audits to once monthly quality improvement meetings,

c. Facility Administrator will review all narcotic audits at least once monthly to ensure completion.

4. Facility Administrator and Facility RCC will ensure on-going compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including diabetes.

Resident 2's 03/01/23 through 04/03/23 MARs and physician's orders were reviewed.

Resident 2 had the following physician's order for Lantus insulin:

* 20 units to be administered at bed time dated 03/14/23; and

* 12 units to be administered at bed time dated 03/31/23.

Resident 2 was administered 20 units of Lantus nightly from 03/31/23 through 04/03/23.

2. Resident 3 was admitted to the facility in 03/2023 with diagnoses including quadriplegia.

Resident 3's 03/01/23 through 04/03/23 MARs and physician's orders were reviewed.

a. Resident 3 had the following orders dated 03/06/23 for Oxycodone to manage pain:

* 10 mg once daily for pain; and

* 5 mg one tablet every 8 hours for breakthrough pain, max of three tablets daily (total Oxycodone of 25 mg daily including daily 10 mg dose).

Resident 3 was administered Oxycodone 5 mg once daily from 03/11/23 through 04/03/23 and Oxycodone 10 mg and 5 mg PRN up to 3 times daily from 03/11/23 through 03/31/23.

Observation of the medication bubble pack on 04/04/23 revealed the Oxycodone 5 mg was ordered to be given PRN.

b. Resident 3 had a physician's order dated 03/06/23 for Bisacodyl suppository as needed for constipation.

Resident 3 was administered the suppository daily from 03/04/23 through 04/04/23.

In an interview on 04/04/23, Staff 11 (MA) confirmed the suppository was administered daily.

The need to ensure medications were administered as ordered was reviewed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/04/23 and 04/05/23. They acknowledged the findings and Staff 2 immediately contacted physicians to clarify the orders.

C303  

OAR 411-054-0055 (1) (f-h) Systems: Treatment Orders

1.Actions to be taken to correct the rule violation include; full audit of physician orders for Resident #2, and #3 to ensure physician orders are being carried out per MD order.

2.The system will be corrected to eliminate further violations as follows: 100% of all resident medication and treatment orders will be reconciled to ensure medications and treatments are dispensed as ordered.

3.Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed.

4.The Nurse, Administrator or trained designee will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure written, signed orders were documented in the residents' facility records for all medications and treatments the facility was administering, and that orders were carried out as prescribed for 3 of 3 sampled residents (#s 2, 4, and 5) whose medications were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 02/2023 with diagnoses including diabetes.

Resident 2's 09/01/23 through 09/19/23 MARs and physician's orders were reviewed.

a. There were no signed orders for:

*Atrovastatin 40 mg given one time daily for lowering cholesterol;

*Clopidogrel 75 mg given one time daily for lowering cholesterol;

*Duloxetine 20 mg given one time daily for depression;

*Ferrous Sulfate 325 mg given one time daily as a supplement;

*Folic Acid 1 mg given one time daily as a supplement;

*Amlodipine/Olmesartan 10-20 mg documented as given on 09/05/23, 09/14/23, and 09/16/23 for high blood pressure;

*Carvedilol 12.5 mg given twice daily;

*Nystatin powder applied twice daily for skin rash; and

*Insulin Aspart injected per sliding scale three times daily for diabetes.

b. Resident 2 has signed orders for Lantus Solostar, 12 units before bed for diabetes.

The medication was not documented as injected on 09/12/23.

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease (COPD) and was receiving hospice services.

Resident 4's 09/01/23 through 09/19/23 MARs and orders were reviewed.

Resident 4 had physician orders for:

*Citalopram 20 mg daily for depression;

*Clopidogrel 75 mg daily for blood clot prevention;

*Tamsulosin 0.4 mg daily for benign prostatic hyperplasia;

*Fluticas/Salmet 250/50 mcg twice daily inhaler for shortness of breath;

*Albuterol Sulfate nebulizer treatment three times daily for COPD.  

The medications were documented as not administered on five days because Resident 4 was sleeping. There was no evidence of staff re-attempting to give the medications.

In an interview with Staff 11 (MA), she explained Resident 4 preferred to sleep in and she acknowledged the medications had not been administered.

3. Resident 5 was admitted to the facility in 05/2018 and was receiving hospice services.

Resident 5's 09/01/23 through 09/19/23 MARs and orders were reviewed.

There were no signed orders for:

*Baza 2% anti-fungal cream applied twice daily; and

*Nystatin powder as needed for rash.

The need to ensure written, signed orders were documented in the residents' facility records for all medications and treatments the facility was administering, and that orders were carried out as prescribed was reviewed with Staff 1 (ED) on 09/20/23. She acknowledged the findings.

1. Actions to be taken to correct the rule violation include; full audit of physician orders for sampled residents to ensure physician orders are being carried out per MD order.

2.The system will be corrected to eliminate further violations as follows: 100% of all resident medication and treatment orders will be reconciled to ensure medications and treatments are dispensed as ordered.

3.Medication reconciliations will be completed on a quarterly basis. Additionally, all new orders will be reviewed and approved by a minimum of two staff. Further daily audits to review missing medications, omissions and PRN usage will be completed.

4.The Nurse, Administrator or trained designee will be responsible for ensuring the corrections are completed and monitored.

Based on observation, interview, and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 3 of 3 sampled residents (#s 2, 4, and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1.  Resident 2  was admitted to the facility in 02/2023 with diagnoses including a diabetes and high blood pressure.

Resident 2's 09/01/23 through 09/19/23 MARs were reviewed and revealed:

a. Amlodipine/Olmesartan 10 to 20 mg once daily for high blood pressure was documented as not available on all days except 09/05, 09/14 and 09/16/23, when it was signed at administered.  In an interview with Staff 11 (MA) and review of the medication bubble packs, on 09/20/23, she confirmed the medication was not available and had not been administered. She acknowledged the dosage was not defined on the MAR. Staff 11 explained clarification for the dosage amount had been requested from the physician.

b. Insulin Aspart per a sliding scale before meals for diabetes was noted to be unavailable for the pre-lunch dose on 09/05/23. In an interview with Staff 11 on 09/20/23, she stated the medication had been available.

2. Resident 4 was admitted to the facility in 08/2023 with diagnoses including chronic obstructive pulmonary disease (COPD) and was receiving hospice services.

Resident 4's 09/01/23 through 09/19/23 MARs and orders were reviewed and revealed:

*Albuterol HFA 90 mcg in-hailer PRN for shortness of breath;

*Albuterol Sulfate 0.083% 3 ml via nebulizer for shortness of breath;

*Lorazepam 0.5 mg as needed for agitation and shortness of breath; and

*Morphine Sulfate solution 5 to 20 mg as needed for pain and shortness of breath.

There were no specific parameters to guide non-licensed staff on which breathing treatment to use first. There were not specific dosing instructions for the Morphine Sulfate.

3. Resident 5 was admitted to the facility in 05/2018 and was receiving hospice services.

Resident 5's 09/01/23 through 09/19/23 MARs and orders were reviewed and revealed:

a. Resident 5 had an order for Quietiapine 25 mg 1/2 tablet twice daily.  

The MAR indicated Quietiapine 25 mg 1 tablet was administered twice daily.

The medication bubble pack was observed with Staff 11 on 09/20/23 and 1/2 a tablet was administered. Staff 11 acknowledged the MAR did not accurately reflect the dosage being administered.

b. Resident 5 had orders for:

*Lidocaine 4% patch as needed for back pain;

*Morphine sulfate 5 mg solution as needed for severe pain; and

*Acetaminophen 325 mg two tablets as needed for pain.

There were no specific parameters to guide non-licensed staff on which pain medication to use first.

*Albuterol Sulfate 0.083% nebulizer treatment for shortness of breath; and

*Budesonide 1 mg in-hailer as needed for shortness of breath.

There were no specific parameters to guide non-licensed staff on which breathing treatment to use first.

*Furosemide 20 mg 1/2 tablet as needed for fluid overload; and

*Spironolactone 25 mg tablet as needed for fluid overload.

There were no specific parameters to guide non-licensed staff on which medication to use first or parameters for determining fluid overload.

*Quietiapine 25 mg 1/2 tablet as needed for anxiety or agitation; and

*Lorazepam 0.5 mg one tablet as needed for anxiety or agitation.

There were no specific parameters to guide non-licensed staff on which behavior medication to use first.

The need to ensure MARs were accurate and included clear parameters for non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (ED) and Staff 13 (RN) on 09/20/23. They acknowledged the findings.

1. Brookside Place will review sampled residents orders agains the MAR to ensure accuracy. Additionally, retraining of medication staff to ensure they know where to look for the mediciations, how to follow the orders as written, and whom to contact in the case of medicaitons missing or unclear orders.

2. Brookside Place will ensure accuracy within the MAR via weekly audits, ongoing training of medication staff, and partnering with pharmacy to ensure recommendations and corrections are implemented.

3. Audits will be done weekly. Training will be done as needed and ongoing.

4. Administrator and/or designee will be responsible for ensuring regular MAR checks are completed and follow up on any missing medications, documentation, etc.

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 a PRN psychotropic. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2021 and was receiving hospice services for end of life care.

Review of the resident's 03/01/23 through 04/03/23 MAR and current physician orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication) one tablet every two hours as needed for agitation or mild anxiety.

The facility administered the Lorazepam to the resident on three occasions in March 2023.

The MARs lacked resident specific parameters for staff describing how the resident expressed agitation and 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 agitation and anxiety and non-drug interventions were developed, attempted, and documented as not effective prior to administration of the medication was discussed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/04/23. They acknowledged the findings.

C330

OAR 411-054-0055 (6) Systems: Psychoactive Medications

1.Actions to be taken to correct the rule violation include;

completing a comprehensive audit of Resident #1 and MAR and adding resident specific parameters for use of PRN psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharm interventions attempted.

2.The system will be corrected so this violation will not happen again by;

a.Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process.

b.The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using.

c.All active PRN psychoactive medications will be reviewed prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits.

3.This area will be evaluated on a quarterly basis prior to

sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received.

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

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering the medication for 2 of 2 sampled resident (#s 4 and 5) who were prescribed PRN psychotropic medications. This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 08/2023 and was receiving hospice services for end of life care.

Review of the resident's 09/01/23 through 09/19/23 MAR and current  orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication) one tablet as needed for agitation or restlessness.

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

2. Resident 5 was admitted to the facility in 08/2023 and was receiving hospice services for end of life care.

Review of the resident's 09/01/23 through 09/19/23 MAR and current  orders revealed an order for Lorazepam 0.5 mg (a psychotropic medication) one tablet as needed for agitation or anxiety with direction to contact hospice before administering.

The MARs lacked resident specific parameters for staff describing how the resident expressed agitation and anxiety.

The need to ensure there were resident-specific descriptions of how the residents expressed agitation and anxiety was discussed with Staff 1 (ED) and Staff 13 (RN) on 09/20/23.

1.Actions to be taken: complete a comprehensive audit of sampled residents and MAR and add resident specific parameters for use of PRN psychoactive medications as well as adding a trigger for staff to document the resident specific non-pharm interventions attempted.

2.The system will be corrected so this violation will not happen again by;

a. Any new order for PRN psychoactive medication to treat mood or behavior issues will be reviewed by the Licensed Nurse through the triple check process.

b.The Licensed Nurse will ensure appropriate resident specific indicators for use are in place as well as non-pharm interventions staff should offer prior to using.

c. All active PRN psychoactive medications will be reviewed prior to quarterly physician orders sent for signature as well as with scheduled PRN medication audits.

3. This area will be evaluated on a quarterly basis prior to sending quarterly physician orders for signature, on a monthly basis with medication administration record audits and daily with triple check review if a new order is received.

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

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 8, and 9) completed all required pre-service orientation training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:

Staff training records were reviewed on 04/04/23 and revealed the following:

There was no documented evidence Staff 6 (MA), hired 11/14/22, Staff 8 (CG), hired 01/25/23, and Staff 9 (CG) hired 2/27/23 completed the following required pre-service orientation elements prior to performing any job duties:

* Infectious disease prevention;and

* Pre-service dementia training, including a certificate of completion.

The need to ensure training was completed by newly hired staff prior to working with residents was discussed with Staff 1 (ED) on 04/04/23. She acknowledged the findings.

C370

OAR 411-054-0070 (3-4) Staffing Requirements and Training: Caregiver Requirements:

1.Actions to be taken to correct the rule violation includes:

             a. Staff members #6, #8, & #9 will complete all

                 pre-service training as required, with

                 documented evidence of training in

                 their respective training files.

2.The following corrections are being made to eliminate future violations:

a.A comprehensive audit of 100% of staff files and

training records to ensure all staff are compliant

with all required pre-service and annual ongoing training.

             b. Facility will update the new-hire orientation to

                 include all required pre-service trainings

b.The facility will create a training tracking grid for staff training. This will include specifically all pre-service training required prior to providing care, all training required within 30 days and to monitor required ongoing training.

3.  This system will be evaluated as follows:

             a. Facility B.O.M or designee will review training grid at

                 least once monthly,              

   b. Facility Administrator will review all new hire

                orientation and training, at least once

                monthly, to ensure compliance,

            c. Facility B.O.M will bring staff training grid to

                Quality Improvement meetings to review

                with IDT, at least once a month.

            d. Facility will schedule new-hire orientation at

                least once monthly, to ensure all pre-service

                training is completed.

4. The Administrator or trained designee will be

    responsible to ensure the corrections are completed and

    monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 6, 8, and 9) had documented demonstration of competency in all required areas and had been trained in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 04/04/23 indicated the following:

* Staff 6 (MA), hired 11/14/22, Staff 8 (CG), hired 01/25/23, and Staff 9 (CG) hired 2/27/23, lacked documented evidence of training in general food safety, serving and sanitation;

* Staff 8 lacked documented evidence of demonstrating competence in:

- Role of service plans; and

- Providing assistance with ADLs.

* Staff 6, Staff 8, and Staff 9 lacked documented evidence of First Aid and abdominal thrust training.

The need to document demonstrated competency in job duties and to complete First Aid and abdominal thrust training within 30-days of hire was discussed with Staff 1 (ED) 04/04/23. She acknowledged the findings.

C372

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff

1.Actions to be taken to correct this rule violation includes:

a.Staff #6 will complete training and provide documentation for food safety & serving sanitation, complete a 1st aid course, receive training and provide return demonstration of abdominal thrust.

b.Staff #8 will receive training and show return demonstration of competency for providing assistance with ADL's and complete a 1st aid course, receive training and provide return demonstration of abdominal thrust.

c.Staff #9 will complete training and provide documentation for food safety & serving sanitation, complete a 1st aid course, receive training and provide return demonstration of abdominal thrust.

2.The following corrections are being made to eliminate future

violations:

c.A comprehensive audit of 100% of staff files and

training records to ensure all staff are compliant

with all required pre-service and annual ongoing training.

             b. Facility will update the new-hire orientation to

                 include all required pre-service trainings

d.The facility will create a tracking spreadsheet for staff training. This will include specifically all pre-service training required prior to providing care, all training required within 30 days and to monitor required ongoing training.

3.  This system will be evaluated as follows:

             a. Facility B.O.M or designee will review training grid at

                 least once monthly,              

   b. Facility Administrator will review all new hire

                orientation and training, at least once

                monthly, to ensure compliance,

            c. Facility B.O.M will bring staff training grid to

                Quality Improvement meetings to review

                with IDT, at least once a month.

            d. Facility will schedule new-hire orientation at

                least once monthly, to ensure all pre-service

                training is completed.

4. The Administrator or trained designee will be

    responsible to ensure the corrections are completed and

    monitored.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 17) had documented demonstration of competency in all required areas and had been trained in First Aid and abdominal thrust within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Review of the facility's training records on 09/20/23 indicated Staff 17(CG) hired 08/01/23, lacked documented evidence of training in:

*General food safety, serving and sanitation;

*First Aid; and

*Abdominal thrust training.

The need to document demonstrated competency in job duties and to complete First Aid and abdominal thrust training within 30-days of hire was discussed with Staff 1 (ED) 09/20/23. She acknowledged the findings.

1. Actions to be taken:

a. Staff #17 will complete training and provide documentation for food safety & serving sanitation, complete a 1st aid course, receive training and provide return demonstration of abdominal thrust.

2. The following corrections are being made to eliminate future violations:

a. An audit of 100% of staff files and training records to ensure all staff are compliant with all required pre-service and annual ongoing training.

b.The facility will create a tracking spreadsheet for staff training. This will include specifically all pre-service training required prior to providing care, all training required within 30 days and to monitor required ongoing training.

3.  This system will be evaluated as follows:

a. administrator or designee will review training grid at least once monthly,              

b. Facility Administrator will review all new hire orientation and training, at least once monthly, to ensure compliance,

c. training grid to be reviewed at Quality Improvement meetings at least once a month.

4. The Administrator or trained designee will be

responsible to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to have documented evidence of 12 hours of annual in-service training, included six hours related to the care of residents with dementia, for 2 of 2 long-term staff (#s 7 and 10) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training hours, based on the anniversary date of hire, were reviewed for Staff 7 (MA), hired 12/13/21, and Staff 10 (CG), hired 07/05/21.

The training records lacked documented evidence of completing six hours of annual in-services related to dementia care.

There need to ensure staff completed 12 hours of on-going training, including six hours related to dementia care, was reviewed with Staff 1 (ED) on 04/04/23. She acknowledged the findings.

C374

OAR 411-054-0070 (6-7) Annual Training and Other Requirements.

1.Actions to be taken to correct this rule violation includes;

a.Staff members # 7 and 8 will complete all annual training, as required.

b.A full complete audit 100% of all other employees to be conducted to ensure that trainings are current and in compliance.

2.The following corrections are being made to ensure no further violation of the rule; facility admin or designee will implement a training grid with all training requirements included, to ensure compliance.

3.The facility admin or designee will audit the training grid at least once weekly, and prior to any new hire starting their job duties. All employees found to be out of compliance with trainings will be scheduled time to complete trainings.

4.The administrator or trained designee will be responsible for ensuring the corrections are completed and monitored.

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

Fire and life safety records from 11/2022 through 03/2023 were requested and reviewed:

* There was no evidence of Fire and life safety instruction in 2022;

* Fire drill records lacked the following components:

- Evacuation time-period needed; and

- Escape routes used.

* Fire drills had been conducted 10/06/22 and 02/02/23. There was no drill completed in 12/2022.  

Fire and life safety training and fire drill documentation requirements was discussed with Staff 1 (ED) And Staff 3 (Maintenance Director) on 04/04/23 and 04/05/23. They acknowledged the findings.

C420

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

1.Actions taken to correct the rule violation will include;

a.Facility will conduct unannounced fire drills every other month at different times of the day, evening and night. No less than 2 of each shift (day/evening/night) annually.

b.Fire and life safety instruction for staff will be provided on alternate months.

c.Community will implement a fire drill tool that encompasses all required pieces including but not limited to; evacuation time period needed, alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills.

d. Evaluation of each resident will be completed to evaluate their ability and needs to evacuate safely.

2.The system will be corrected so this violation does not happen again by completing a comprehensive review of current fire drill forms to ensure they meet the requirements of the Oregon Administrative Rule and in servicing administration or designee conducting fire and life safety drills and education on process and documentation required.

3.The area needing correction will be evaluated monthly during IDT meetings.

4.The administrator or designee will be responsible to ensure corrections are completed and monitored to ensure continued compliance.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, failed to ensure a written record of fire safety training, including content of the training sessions and the residents attending, was kept. Findings include, but are not limited to:

There was no documented evidence residents had been instructed on fire and life safety procedures upon admission and re-instruction at least annually, including a written record of fire safety training, with content of the training sessions and the residents attending.  

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instruction at least annually, maintaining a written record of the training, including content and the residents attending, was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 04/04/23 and 04/05/23. They acknowledged the findings.

C422

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

1.Action to be taken to correct this rule violation includes; all residents will be instructed on 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 safe and re-instructed annually.

2.The system will be corrected so this violation will not happen again by ensuring new residents will be instructed within 24 hours of move in and re-instructed annually for 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.

3.The areas needing correction will be audited daily at IDT stand up meeting and clinical meeting with a new resident move in.

4.The Administrator or designee will be responsible for ensuring corrections are completed and monitored to maintain compliance.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire, failed to ensure a written record of fire safety training, including content of the training sessions and the residents attending, was kept. This is a repeat citation. Findings include, but are not limited to:

There was no documented evidence residents had been instructed on fire and life safety procedures upon admission and re-instruction at least annually, including a written record of fire safety training, with content of the training sessions and the residents attending.  

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instruction at least annually, maintaining a written record of the training, including content and the residents attending, was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 09/20/23. They acknowledged the findings.

1.Action to be taken to correct: all residents will be instructed on 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 safe and re-instructed annually.

2.The system will be corrected so by ensuring new residents are instructed within 24 hours of move in and re-instructed annually for 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.

3.The areas needing correction will be audited daily at stand up meeting and clinical meeting with a new resident move in.

4.The Administrator or designee will be responsible for ensuring corrections are completed and monitored to maintain compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to  C 262, C 302, C 303, C 330, C 372, C 422, C 655, and H 1518.

1. Brookside Place will immediately begin correcting the deficiencies noted in the survey by means of audit, education, correction, and documentation in each of the noted areas.

2. The systems will be reviewed and evaluated to identify where the failures occurred and corrections will be implemented to avoid repeating those same failures. This may include utilizing outside resources when necessary.

3. All areas of deficiency will be evaluated each week, and more often as needed, to ensure corrections have been implemented.

4. Administrator and/or designee will monitor each of the identified areas to ensure the corrections have been implemented and are being followed ongoing.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair and to ensure the electronic code used for the front exit was clearly posted for residents, visitors, and staff use. Findings include, but are not limited to:

Observations of the facility on 04/03/23 revealed the following:

* Rooms 105 and 130 had damage to the doors, kick plate, and door jambs creating hazards; and

* The front entrance was secured with a keypad lock. The code was not posted.

The surveyor, Staff 1 (ED), and Staff 3 (Maintenance Director) toured the environment on 04/03/23. The need to post the exit code was discussed. They acknowledged the findings.

C613

OAR 411-054-0300 (4) (d-i) General Building: Doors-Walls, Cleanable

1.Actions to be taken to correct the violation of this rule includes;

a.The keypad code will be posted at the front door, easily accessible for staff, visitors and resident use.

b.Maintenance will complete repair of rooms 105 & 130 doors, kick plates, and door jambs

2.The system will be corrected to eliminate further violation of this rule by; a weekly walk-through of the community to be completed to observe and monitor for areas needing repair and required postings at doors. A maintenance repair request system to be implemented and staff trained on how to report maintenance needs for repairs.

3.The area needing correction will be evaluated daily at IDT stand up meetings, and monthly during quality assurance review.

4.The administrator, maintenance director and or designee will be responsible for ensuring corrections are completed and monitored to maintain compliance.

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

In interviews with Residents 1, 2 and 3 on 04/03/23 and 04/04/23, a lockable storage drawer was observed in their units. All three sampled residents stated they did not have a key to the drawer.

On 04/03/23, 04/04/23, and 04/05/23 multiple un-sampled residents interviewed confirmed, although they had a lockable storage space in their apartments, they did not have a key to the space.

The need to ensure residents had a key to their lockable storage space was discussed with Staff 1 (ED) on 04/05/23. She acknowledged the findings.

C615

OAR 411-054-0300 (5) Resident Units

1. Resident #1, #2 and #3 will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their key to their lockable storage area.

Additionally, Resident #1, #2 and #3 service plan will be reflective of the plan to operate and maintain their key to their lockable storage area.

2. All residents will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their key to their lockable storage area.

Additionally, all resident service plans will be reflective of the plan to operate and maintain his/her key to their lockable storage area.

3.This system will be evaluated with new move ins on admission and quarterly thereafter.

4. The Administrator will be responsible for ensuring the system has been corrected.

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

During an environmental walk-through on 04/03/23, the glass panel doors on the fireplace in the front common room was too hot to touch. Staff 1 (ED) confirmed the extreme temperature and the fireplace was turned off.

The need to ensure residents could not come into incidental contact with fireplace elements that exceeded 120 degrees F was discussed with Staff 1.  She acknowledged the findings.

C640

OAR 411-054-0300 (8) Heating and Ventilation

1.Actions to be taken to correct the violation of this rule includes; fireplace to be made inoperable until an adequate safety screen can be put in place. A safety gate/screen to be purchased and installed providing a distance from heat source ensuring surface of grate does not exceed 120 degrees Fahrenheit.

2.The system is to be corrected to eliminate further violation by; a review of all heat sources including but not limited to fireplaces, wall heaters to be added to monthly quality assurance checklist for maintenance.

3.The area to be corrected will be evaluated monthly with maintenance quality assurance safety checks. Maintenance to review monthly with administrator and IDT at monthly quality assurance meetings.

4.The administrator, maintenance director or designee will be responsible to ensure corrections are completed and monitored to maintain 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 systems to alert staff when residents exited the building. Findings include, but are not limited to:

During the survey, the facility was identified to have two doors that exited into the facility's inner courtyard. The exit to the courtyard from the hallway lacked an alarming device to alert staff when residents exited.

On 04/04/23, the lack of alarms or other acceptable system was shared with Staff 1 (ED) and Staff 3 (Maintenance Director). They confirmed there was no system to alert staff when residents exited to the courtyard from the hallway.

C655

OAR 411-054-0300 (11-13) Call System

1.Actions to be taken to correct the violation of this rule includes; door alarms to be installed on all doors leading to an exit of the building

2.The system is to be corrected to eliminate further violation by; adding review of alarms on all exterior exit doors to weekly quality assurance review completed by maintenance.

3.The area to be corrected will be evaluated monthly with maintenance quality assurance safety checks. Maintenance to review monthly with administrator and IDT at monthly quality assurance meetings.

4.The administrator, maintenance director or designee will be responsible to ensure corrections are completed and monitored to maintain 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. This is a repeat citation. Findings include, but are not limited to:

During the survey, the facility was identified to have two doors that exited into the facility's inner courtyard. The exit doors lacked an alarming device to alert staff when residents exited.

On 09/20/23, the lack of alarms or other acceptable system was shared with Staff 1 (ED) and Staff 3 (Maintenance Director). They confirmed there was no system to alert staff when residents exited to the courtyard.

1. Actions to be taken to correct the violation of this rule includes; door alarms to be installed on all doors leading to an exit of the building

2. The system is to be corrected to eliminate further violation by; adding review of alarms on all exterior exit doors to weekly quality assurance review completed by maintenance.

3. The area to be corrected will be evaluated monthly with maintenance quality assurance safety checks. Maintenance to review monthly with administrator and IDT at monthly quality assurance meetings.

4. The administrator, maintenance director or designee will be responsible to ensure corrections are completed and monitored to maintain compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated need. Findings include, but are not limited to:

Review of records for Residents 2 and 3 revealed no documented evidence the residents had been evaluated for the ability to manage keys to their rooms.

In interviews with Residents 2 and 3 on 04/03/23, they indicated they did not have keys to their units.

The need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys based on those evaluations was discussed with Staff 1 (ED) and Staff 2 (RN Wellness Director) on 04/04/23. They acknowledged the findings.

H1518

OAR411-004-0020(2)(e) Individual Door

Locks: Key Access

1. Resident #2 and #3 will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their apartment key.

Additionally, Resident #2 and #3 service plan will be reflective of the plan to operate and maintain their apartment key.

2. All residents will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their apartment key.

Additionally, all resident service plans will be reflective of the plan to operate and maintain his/her apartment key.

3.This system will be evaluated with new move ins on admission and quarterly thereafter.

4. The Administrator will be responsible for ensuring the system has been corrected.

Based on interview and record review, it was determined the facility failed to ensure residents who lived in the facility were provided a key to their units per their evaluated need. This is a repeat citation. Findings include, but are not limited to:

Review of records for Residents 4 and 5 revealed no documented evidence the residents had been provided keys, or had been evaluated for the ability to manage keys to their rooms.

In an interview with Staff 1 (ED) on 09/19/23, she indicated keys had been provided to residents' family members. She acknowledged there was no documented evidence the residents had been evaluated and determined unable to manage the keys.

The need to ensure all residents were evaluated for the ability to manage keys to their units and provided keys based on those evaluations was discussed with Staff 1 (ED). She acknowledged the findings.

1. Resident #4 and #5 will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their apartment key. Their service plans will be reflective of the plan to operate and maintain their apartment key.

2. All residents will be evaluated to determine whether they are appropriate to own, operate, and maintain the use of their apartment key.

Additionally, all resident service plans will be reflective of the plan to operate and maintain his/her apartment key.

3.This system will be evaluated with new move ins on admission and quarterly thereafter.

4. The Administrator will be responsible for ensuring the system has been corrected.