Print Inspection: DR26

The findings of the re-licensure survey, conducted 06/12/23 through 06/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 revisit to the re-licensure survey of 06/14/23, conducted 02/21/24 through 02/22/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 06/13/23 the kitchen was observed to need cleaning and repair in the following areas:

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

* Floor throughout the kitchen including the dry storage area;

* Stainless steel upper and lower shelves throughout the kitchen;

* Multiple black serving carts;

* Warewasher;

* Ice cream freezer;

* Wooden cabinets throughout the kitchen;

* Drawer to the food warmer underneath the prep table;

* Entryway doors and door frames, door to dry storage area and walk-in refrigerator door;

* Ceiling and wall vents throughout the kitchen;

* Floor drains in front of gas range and near walk-in refrigerator; and

* Grease trap across from three compartment sink.

b. The following equipment was in need of repair:

* Gray serving cart had large cracks on the frame;

* Juice machine was missing a spill tray;

* Cabinet underneath juice machine was missing a door; and

* Grease trap across from three compartment sink was missing tile pieces from the perimeter.

The need to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000, was discussed with Staff 1 (ED) and Staff 6 (Dining Services Director) on 06/14/23. They acknowledged the findings.

1. The kitchen will receive a deep clean including all areas specifically identified during survey. The serving cart will be removed, the juice machine, cabinet, and tile will be repaired.

2. The Dining Services Director and Executive Director will receive additional training on kitchen cleaning and developing a routine schedule. The Cooks and Dining Services Aides will receive additional training on maintaining a clean kitchen.

3. The Dining Services Director will review weekly per the Quality Assurance - Dining Services Review Schedule and a kitchen inspection will be completed quarterly per the QA program to identify any needed repairs.

4. The Executive Director will be responsible for ensuring corrections are completed and monitored.

2. Resident 1 was admitted to the facility in 12/2022 with diagnoses including congestive heart failure.

The resident's 06/13/23 service plan and interim service plans were reviewed during the survey. The service plan was not reflective and failed to provide clear instruction to staff regarding the resident's mobility including:

* Left sided weakness;

* Fall interventions; and

* Use of electric mobility scooter.

The need to ensure Resident 1's service plan was reflective and provided clear instruction to staff was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated quarterly, reflective of residents' current status and care needs, were readily available to staff and provided clear instruction to staff for 2 of 5 sampled residents (#s 1 and 6) whose service plans were reviewed. Findings include, but are not limited to:  

1. Resident 6 was admitted to the facility in 03/2022 with diagnoses including chronic obstructive pulmonary disease, heart failure and hypertension.

Resident 6's current service plan, dated 09/28/22, and temporary service plans failed to reflect the resident's care needs and lacked specific instruction to staff in the following areas:

* Use of assistive devices;

* Level of assistance with transfers and ambulation;

* Orientation;

* Judgment;

* Ability to leave community without supervision;

* Resistance to care;

* Grooming, dressing and nail care ability;

* Incontinence;

* Independence with oxygen;

* Fall risk; and

* Weight loss.

An observation on 06/13/23 at 2:05 pm revealed Resident 6 required assistance to assist him/her with oxygen usage as prescribed.

Interview with Staff 3 (Wellness Director) on 06/13/23 revealed quarterly service plans had not been completed for Resident 6. An updated service plan, dated 06/13/23, was provided on the same day.

The need to ensure service plans were reflective of the resident's current care needs, updated quarterly with changes and provided clear direction to staff was discussed with Staff 1(ED) and Staff 3 on 06/14/23 at 11:15 am. They acknowledged the findings.

1. All resident service plans will be reviewed to ensure the plans are reflective of resident needs and with clear instruction regarding delivery of service.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy.

3. The Wellness Director will review weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring 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 consisted of the resident, the resident's legal representative if applicable, any person of the resident's choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 3 of 5 sampled residents (#s 1, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 5 and 6's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 06/14/23 at 11:15 am, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 3 (Wellness Director). They acknowledged the findings.

1. All resident service plans will be developed by a service planning team.  

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy, Pre-Service Plan Review, and the Service Plan Development and Meeting Notes.

3.  The Wellness Director(s) will review this area weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to develop interventions, communicate the interventions to staff on each shift, evaluate implemented interventions for effectiveness and monitor conditions with progress noted at least weekly for 3 of 5 sampled residents (#s 1, 2 and 6) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 12/2022 with diagnoses including congestive heart failure.

The resident's progress notes, dated 03/12/23 through 06/12/23 and interim service plans (ISP's) were reviewed and revealed the following:

* 03/31/23 - Medication change: NovoLog insulin FlexPen 70/30 increase am dose to 46 units and increase pm dose to 35 units;

* 4/06/23 - Medication change: Lasix increase to 40 mg daily;

* 04/07/23 - Fall;

* 04/08/23 - High CBG over 600;

* 04/18/23 - Fall;

* 04/25/23 - High CBG over 600;

* 05/06/23 - Medication change: NovoLog FlexPen 70/30 increase am dose to 52 units; and

* 06/05/23 - Fall.

a. There was no documented evidence the facility developed interventions, communicated the interventions to staff on each shift and monitored the conditions with progress noted at least weekly through resolution for each of Resident's 1's short-term changes of condition.

b. There was no documented evidence previously implemented interventions for the resident's falls were evaluated for effectiveness or if new interventions needed to be developed.

Resident 1's changes of condition, lack of interventions and monitoring were discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 06/2018 and was noted to have experienced recent confusion. The resident's progress notes, dated 03/12/23 through 06/12/23 and interim service plans (ISP's) were reviewed and revealed the following:

* 04/08/23 - Medication change: donepezil increase to 10 mg;

* 04/26/23 - Fall;

* 04/28/23 - Urinary Tract Infection and medication change: begin cefdinir 300 mg daily;

* 04/29/23 - Behaviors;

* 05/02/23 - Medication change: begin mirtazipine 7.5 mg daily; and

* 05/08/23 - Behaviors.

There was no documented evidence the facility developed interventions, communicated the interventions to staff on each shift and monitored the conditions  with progress noted at least weekly through resolution for each of Resident's 2's short-term changes of condition.

Resident 2's changes of condition, lack of interventions and monitoring were discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 03/2022 with diagnoses including chronic obstructive pulmonary disease, hypertension and heart failure.

Progress notes dated 04/06/23 through 06/12/23, interim service plans, skin care logs and incident reports were reviewed. The following changes of condition were identified:

* 04/26/23: Medication change, begin antibiotic, Macrobid;

* 05/19/23: "Very weak and unstable to stand up...resisting to wear nasal cannula."; and

* 06/08/23: Medication changes, discontinue afternoon dose of lasix and potassium and new order for ear drops, carbamide peroxide.

There was no documented evidence actions or interventions were determined, interventions communicated to staff, and progress was documented weekly through resolution for the short term changes of condition.

In an interview with Staff 3 (Wellness Director) on 06/14/23 at 9:05 am, he confirmed the facility failed to monitor the changes of condition.

The need to ensure Resident 6's short-term changes of condition were evaluated to determine and document what action or intervention is needed for the resident, the determined action or intervention be communicated to staff on each shift, and were monitored with progress noted at least weekly through resolution was discussed with Staff 1 (ED), and Staff 3  on 06/14/23 at 11:15 am. They acknowledged the findings.

1. All resident records will be reviewed to ensure all change of condition is identified with appropriate action (evaluation, intervention, service plan update, and resident monitoring).

2.  The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Change of Condition policy. All direct care staff will receive additional training on the Stop and Watch early warning tool procedure.

3.  The Executive Director, Wellness Director(s), and Wellness Nurse will review this area daily per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and 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 (# 1) 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 06/12/23, Resident 1 was identified to be administered insulin via pen injector by non-licensed staff. Resident 1's MAR, reviewed from 06/01/23 - 06/12/23, revealed blood sugar level checks and insulin injections had been done by Staff 4 (Wellness Coordinator) and Staff 12 (MT) on several occasions.

Review of delegation documentation on 06/14/23 revealed the following:

a. The initial delegation for Staff 12 dated 03/29/23 lacked:

* Willingness of  Staff 12;

* Staff 12's understanding the task was client specific and not transferable; and

* The RN took responsibility for delegating the task and ensured supervision would occur for as long as the RN was supervising performance.

b. Re-delegation for Staff 12, dated 05/31/23 lacked the following:

* Nursing assessment and condition of the client, and determination client remained stable and predictable;

* Individual observation, return demonstration of competence by Staff 12; *Conformation Staff 12 remained capable and willing to safely perform the task; and

* Conformation the re-evaluation was completed within 60 days of the initial delegation.

c. Re-delegation for Staff 4, completed on 03/21/23 lacked:

* Nursing assessment and condition of the client and determination client remained stable and predictable;

* Individual observation, return demonstration of competence by Staff 4.

* Conformation Staff 4 remained capable and willing to safely perform the task; and

* Conformation the re-evaluation was completed within 60 days of the initial delegation.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) and Staff 2 (RN) on 06/14/23. They acknowledged the findings.

1. All delegation records for residents receiving delegated services will be reviewed for appropriate documentation.

2. The Wellness Nurse will receive additional training on the Delegation Policy, RN Delegation Form and will review the OR Delegation Self Study for the RN.

3. The Wellness Nurse will review this area weekly per the Quality Assurance - Clinical Review Schedule.

4.The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents had a physician's or other legally-recognized practitioner's order of approval for self-administration of prescription medications, for 1 of 1 sampled resident (# 3) who self-administered their medications. Findings include, but are not limited to:

The records indicated Resident 3 self-administered his/her own medications. This was confirmed by facility staff.

Resident 3 did not have an order from a physician indicating approval for the resident to self-administer his/her prescription medications.

The lack of signed orders indicating a physician's approval for Resident 3 to self-administer his/her medications was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23. They acknowledged the findings. No additional documentation was provided.

1. All resident records will be reviewed to identify self-administration of medication and ensure that there are orders from the primary care provider as well as a self-medication assessment.

2. The Executive Director and Wellness Nurse will receive additional training on the Self-Administration of Medication section of the Evaluation and Service Plan.

3. The Wellness Nurse will review this area quarterly and with each new order per the Quality Assurance - Clinical Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to beginning job responsibilities for 1 of 3 new staff (#13) and pre-service dementia care training was completed prior to providing care to residents for 2 of 2 new staff (#s 13 and 16) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 06/14/23 at 10:00 am with Staff 17 (Business Office Director).

a. There was no documented evidence Staff 13 (CG), hired 04/04/23, completed Infectious Disease Prevention training for pre-service orientation.

b. There was no documented evidence Staff 13 or Staff 16 (MT) completed one or more of the following pre-service dementia care topics:

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

* Techniques for understanding, communicating, and responding to behaviors and reducing the use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

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

The need to ensure all new staff complete the required pre-service training within the specified time frames was discussed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23 at 11:15 am. They acknowledged the findings.

1. All employee records will be audited for compliance and completion of all required training.

2. The Executive Director, Business Office Director, and Wellness Director will receive additional training on new hire training requirements and the Staff Records Checklist.

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including at least six hours of dementia care training, for 2 of 2 long-term staff (#s 14 and 15). Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 17 (Business Office Director) on 06/14/23 at 10:00 am. The following was noted:

Staff 14 (MT) and Staff 15 (MT), both hired on 04/07/21, lacked documented evidence of 12 hours of annual in-service training including at least six hour of dementia care training.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (ED) and Staff 3 (Wellness Director) on 06/14/23 at 11:15 am.

1. All employee records will be audited for compliance and completion of at least 12 hours of annual in-service training including 6 hours of dementia care.

2. The Executive Director, Business Office Director, and Wellness Director will receive additional training on annual training requirements and monitoring the Relias completion reports.

3. The Business Office Director will review weekly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required components. Findings include, but are not limited to:

On 06/13/23, fire drill records dated 12/2022 through 05/2023, were reviewed and showed the facility failed to document the following required components:

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* Number of occupants evacuted.

On 06/13/23, the need to ensure all required components of fire drills were documented was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director). They acknowledged the findings.

1. The Executive Director and Maintenance Director will receive additional Training on the Fire Life Safety Training & Drill Flow Chart, and the Fire Drill and Evacuation Checklist.

2. See number one above.

3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually.  Findings include, but are not limited to:

Fire drill records from 12/2022 through 05/2023 were reviewed.

The facility lacked documentation that residents were instructed on fire and life safety procedures at least annually and more if needed.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1(Executive Director) and Staff 5 (Maintenance Director) on 06/14/23. They acknowledged the findings.

1. The community will complete and Annual Resident Safety Training for all residents in the Assisted Living.

2. The Executive Director and Mainteance Director will receive additional training on the Fire and Life Safety Annual Resident Safety Training Documentation.

3. The Maintenance Director will review with each new move-in and annually per the New Resident Checklist and Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

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

The facility was toured on 06/13/23. The following issues were identified:

* There were gouges and scratches to exit door near first floor laundry;

* There were gouges and scratches to the kitchen door and doorframe;

* There were dark spots and stains on the rugs in the lobby of the ALF (Bldg A), the first floor hallway from the lobby past the kitchen, and the staircase in lobby going to the second floor;

* Building B had spots and stains on the carpet on bridge and in front of Rooms B 204, B 213 and B 219;

* The floors in laundry rooms on first and second floors had debris on the them;

* The sink in first floor laundry room had dirt/debris build up;

* The first floor laundry room had debris on the countertops; and

* Multiple small benches throughout the second floor of buildings A and B had stains on the fabric.

The areas needing cleaning and repair were reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 06/14/23. They acknowledged the areas needing cleaning and repair.

1. Doors will be cleaned and repainted as needed, the common area carpet will be cleaned where soiled, and the laundry rooms will receive a deep clean to include the floors and sinks.

2. The Executive Director and Maintenance Director will receive additional training on the Quartelry Building Inspection.

3. The Maintenance Director will review Quarterly per the Quality Assurance - Maintenance Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.