Print Inspection: CXBQ

The findings of the re-licensure survey, conducted 03/27/23 through 03/29/23, 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 for 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 03/29/23, conducted 11/15/23, 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 observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current status, provided clear direction to staff regarding delivery of services and were reviewed and updated following a significant change of condition for 1 of 3 sampled residents (#1) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2022 with diagnosis including hypertension.

Observations of the resident, interviews with staff, Witness 1 (family member) and Witness 2 (family member), review of service plans and evaluations were conducted during the survey.

The current service plan updated on 03/24/23, after a significant change of condition, failed to be reflective of the resident's current status and provide clear instructions to staff in the following areas:

* One person physical meal assistance;

* Receiving room trays verses eating lunch and dinner in the dining room;

* Ability to use microwave, toaster and small appliances in apartment and access food independently;

* Weight changes (loss and gain) including interventions;

* Walking independently verses one person assistance with walker or wheelchair escort;

* Two person assistance with gait belt for transfers;

* Two person assistance for toileting, including two person incontinent care completed in bed;

* Use, risk and precautions related to siderails;

* Type of hospice services the resident would receive;

* Ability to use room key;

* Ability to complete laundry tasks;

* History of tobacco use; and

* Use of oxygen and nebulizer including monitoring instructions.

The need to ensure service plans were reflective of Resident 1's current status and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/29/23. They acknowledged the findings.

1.Resident #1's service plan was corrected to include clear instructions for current status including: meal assistance needs, when meal trays would be needed, ability to use microwave, toaster and small appliances in her apartment, any weight changes including interventions, ambulation and transfer assistance, siderail risk and precautions, hospice services receiving, ability to use room key, ability to complete laundry, history of tobacco use and use of oxygen or nebulizer with monitoring instructions.

2.Service Plans will be reviewed timely and contain current status and interventions as identified with resident evaluation. Changes to service plan will be captured with temporary service plan and service plan updates.

3.Upon move-in, within 30 days of move-in, every 90 days and with significant changes in condition. TSPs will be reviewed weekly for changes in condition.

4.ED, WD and RSD

Based on interview and record review, it was determined the facility failed to monitor each resident consistent with his or her evaluated needs and failed to ensure short term changes of condition were monitored through resolution  for 2 of 3 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 12/2022 with diagnoses including muscle weakness, anemia and colon cancer. A review of the clinical record revealed the following:

Progress notes and "Health Professional Communication" forms were reviewed and revealed the resident had experienced the following changes of condition:

* 01/09/23: "[Resident] has increased edema ...";

* 02/21/23: "Resident attempted to self transfer and fell on his/her left side";

* 03/08/23: "Increasing anemia, decline in renal function, black stool"; and

* 03/08/23: Medication changes, discontinue apixaban (anticoagulant), vitamin D and Senna.

The facility lacked documented evidence the conditions and medication changes were monitored with progress noted at least weekly through resolution.

The need to ensure Resident 2's short term changes of condition were monitored  with progress noted at least weekly through resolution was discussed with Staff 1 (ED), and Staff 2 (Resident Services Director) on 03/29/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility on 03/20/23 with diagnoses including age related physical debility.

Admission referral documents and the facility's move-in evaluation dated 03/13/23 and 03/16/23 respectively, were reviewed and revealed the resident had experienced the following skin conditions:

* Right knee skin tear;

* Left knee blister;

* Spot on right heel; and

* Wound on buttock.

There was no documented evidence the facility monitored the resident's skin between 03/16/23 and the time of the survey 03/27/23.

In an interview with Staff 2 (Resident Services Director) on 03/28/23, she confirmed the facility failed to monitor the skin conditions after the resident moved into the facility.

The facility's failure to monitor the resident consistent with his/her evaluated needs  and service plan was discussed with Staff 1 (ED) and Staff 2 on 03/29/23. They acknowledged the findings.

1.Resident #2 has passed away. Resident #3 has been assessed and service plan updated to reflect current care needs for wounds, including coordination with home health for wound care until resolved. Temporary service plan and monitoring is in place and will continue with weekly nursing assessments at minimum until resolved.

2.All changes of condition will be assessed timely and monitored weekly by LN, or RN, as indicated until resolve. Service plans will be updated based off nursing assessment as needed.

3.Weekly for change in condition assessments, quarterly for careplan updates

4.WD, RN, ED or RSD

Based on interview and record review, it was determined the facility failed to ensure an RN assessment, including documentation of findings, resident status and interventions made as a result of the assessment, was completed for a significant change of condition for 1 of 2 sampled residents (#1) who experienced a significant decline in ADL ability and admission to hospice services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 6/2022 with diagnosis including hypertension.

The resident was admitted to the hospital on 03/22/23 related to hypertension. A progress note dated 03/24/23 noted a return from the hospital and admission to hospice services due to a significant change in ADL care, which included full assistance with all ADL care needs. This constituted a significant change of condition that required an RN assessment.

There was no documented evidence the facility RN had completed a significant change of condition assessment that included documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed following a significant change of condition was discussed with Staff 1 (ED), Staff 2 (Resident Services Director) on 03/29/23. They acknowledged the findings.

1.Resident #1 was assessed for significant change in condition. Assessment has been documented and service plan updated to reflect changes. Resident will be monitored on alert charting until change in condition is resolved with weekly nurse assessments.

2.All significant changes in condition will be assessed timely for changes in service plan and monitoring with RN involvement within 48 hours for service plan update. Resident will be monitored until change in condition resolves.

3.Weekly assessments and quarterly service plan updates

4.WD, RN, 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 (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 03/27/23, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Initial delegation records for Staff 2 (Resident Services Director) and Staff 9, 13 and 14 (MTs), reviewed on 03/28/23, lacked documentation in the following areas:

* Rationale that the task could be safely delegated to the CG;

* Rationale for how frequently the client should be reassessed by the RN; and

* Rationale for how frequently the unlicensed person(s) should be supervised and reevaluated based on the competency of the caregiver;

*Reevaluation completed within 60 days of initial delegation; and

* Staff 14 lacked documentation the RN took responsibility for the delegated task and ensured supervision would occur.

The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was reviewed with Staff 1 (ED) and Staff 2 on 03/28/23. They acknowledged the findings.

1.Delegation documentation will be completed for all non-licensed staff administering insulin to diabetic residents, including documentation for resident #4. Documentation will include: rationale for how the task was delegated safely, frequency of resident assessment, frequency of staff supervision and reevaluation and RN responsibility and supervision for delegated task.

2.Appropriate delegation in accordance with OSBN division 47 will be completed prior to all non-licensed staff administering insulin to diabetic residents.

3.Prior to non-licensed staff administering insulin, within 60 days of initial delegation and not exceeding 180 days thereafter.

4.RN, WD, ED

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications at move-in for 1 of 1 sampled resident (#3) who self-administered medications. Findings include, but are not limited to:

Resident 3 was admitted to the facility on 03/20/23 with diagnoses including age related debility.

A physician order noted the resident was able to self-administer medications.

An evaluation dated 03/27/23 noted the resident's ability to safely administer the medications.

In an interview on 03/29/23 at 1:38 pm, Staff 2 (Resident Services Director) confirmed the resident had been self-administering his/her medications for a week before the facility evaluated the resident's ability to so safely.

The need to complete evaluations of a resident's ability to safely self-administer medications upon move-in and at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 03/29/23. They acknowledged the findings.

1.Resident #1's self-medication assessment is completed and documented in chart.

2.All resident's who wish to self-medicate will be assessed for ability to safely self-administer medications with a valid provider's order, upon move-in and at least quarterly.

3.Prior to self- administering medications and quarterly.

4.ED, WD, RSD

Based on observation, interview and record review, it was determined the facility failed to ensure a thorough assessment had been completed by an RN, PT or OT, and caregivers had been instructed on the correct use and precautions related to the use of the device for 1 of 2 sampled resident (#1) who used siderails. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2022 with diagnoses including history of falling.

Observations on 03/27/23 revealed one quarter length side rail placed at the head of the hospital bed and in the up position while the resident was laying in bed.

a. There was no documented evidence an RN, PT or OT completed an assessment for use of the side rail.

b. The facility failed to document the following:

* The resident specifically requested or approved of the device;

* The facility had informed the individual of the risks and benefits associated with the device;

* Other less restrictive alternatives evaluated prior to the use of the device;

* Instructed caregivers on the correct use and precautions related to the use of the device; and

* Use of the siderail, risks and precautions were included in the service plan.

The need to ensure an RN, PT or OT assessed the use of the device, the facility evaluated all required areas and the assistive device with restraining qualities was included on the resident service plan was discussed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/29/23. They acknowledged the findings.

1.Resident #1's side rail was assessed and assessment documented in resident chart including resident and PT/OT request, resident informed of risks and benefits; less restrictive alternatives documented; use of siderail, risks and precautions were added to service plan. Staff will complete Inservice on correct use and precautions of devices prior to compliance date of 5/28/23.

2.Residents or third-party providers requesting supportive devices with restraining qualities will be assessed per regulation prior to implementation of device including documentation of less restrictive alternatives. Staff will be in-serviced on supportive devices with restraining qualities annually at minimum.

3.Supportive device assessments will be conducted prior to implementation, quarterly and for change in condition.

4.RD, WD, ED

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 9 and 10) completed pre-service dementia training before providing care and services for residents. Findings include, but are not limited to:

Staff training records reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/29/23 identified the following:

Staff 9 (MT) hired on 01/18/23 and Staff 10 (CG) hired on 02/01/23 lacked documentation pre-service dementia training was completed before providing care to residents.    

The need to ensure pre-service dementia training was completed before providing care to residents was discussed with Staff 1 and Staff 2 on 03/29/23. They acknowledged the findings.

1.All staff training files will be reviewed for completion of pre-service dementia training. Files missing required training will be assigned and completed by compliance dated of 5/28/23. Documentation of completion of trainings will be filed in staff training file.

2.Prior to providing care to residents, all staff will complete approved pre-service dementia training.

3.Prior to new hires working shifts.

4.ED, RSD

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 9 and 10) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/29/23 identified the following:

Staff 7 (CG), hired on 01/10/23, Staff 9 (MT), hired on 01/18/23, and Staff 10 (CG), hired on 02/01/23, lacked demonstrated competency of skills in all assigned job duties within 30 days of hire including, but not limited to:

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

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and

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

The need to ensure competency was demonstrated within the first 30 days of hire was discussed with Staff 1 and Staff 2 on 03/29/23. They acknowledged the findings.

1.All staff training files will be reviewed for completion of demonstrated competency of skills in all assigned job duties within first 30 days of hire. Including: role of service plans, identification of changes in residents' physical, emotional and mental functioning and documentation and reporting on changes in condition, and conditions that require assessment, treatment, observation and reporting. Staff files that are missing these trainings, will be assigned and completed prior to compliance date of 5/28/23.

2.Training schedules will be implemented upon hire. Staff will complete prior to 30 days of employment. Trainings will include demonstration of skills and competency. Documentation will be retained in staff training file.

3.Upon hire, prior to 30 days, quarterly

4.ED, RSD