Print Inspection: EYG6

The findings of the re-licensure survey conducted 10/24/22 through 10/27/22 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 first re-visit to the re-licensure survey of 10/27/22, conducted 03/15/23 through 03/16/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 10/27/22, conducted on 06/21/23, 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 interview and record review, it was determined the facility failed to ensure the preparation, completeness, and accuracy of documentation or records for 7 of 10 sampled residents (#s 1, 3, 4, 5, 8, 9, and 10) whose records were reviewed. Findings include, but are not limited to:

During the survey resident records were reviewed and were found to be missing or were incomplete in multiple areas, including signed physicians' orders, hospital discharge paperwork, evaluations and monitoring, incident investigations, service plans, and RN assessments.

On 10/26/22, the need to ensure facility records were accurate and complete was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director). They acknowledged the findings.

OAR 411-054-0025 Facility Administration Records

1.     Residents 1,3,4,5,8,9 and 10 records have been reviewed in the areas of signed physician's orders, hospital discharge documents, evaluations and monitoring, incident investigations, service plans and RN assessments. These areas have been updated to reflect the resident's current status.

2.      Facility wide audit will be conducted as per cited OAR's to reflect the resident's current status. (See TAG C303, C280, C270 and C260).

3.Identified facility staff will monitor through the above specific TAGS on predetermined timeframes. (See individual TAGS for specifics).

4.Daily 'Clinical Meeting' as well as Nursing Workflow have been redesigned for accuracy and efficiency.

5.     Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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:

The facility used two kitchens and a cafe' to prepare resident meals, they were toured on 10/24/22 at 10:24 am. The following areas were in need of cleaning and/or repair:

* The flooring was damaged, stained, and deteriorating in several areas across the kitchens;

* The ceiling vents in both kitchens were covered in dust and debris;

* There were multiple areas of patchy, damaged walls (behind the toaster, on the wall to the left of the coffee maker) creating uncleanable surfaces;

* There was a hole approximately 4 feet by 6 feet of missing ceiling tile in the far right corner of the dry storage room, exposing pipes and the wall interior;

* There was a hole approximately 2 feet by 3 feet above the kitchen prep sink, exposing pipes and the wall interior; and

* The fan affixed to the far wall in the café kitchen was covered in dust/debris.

The kitchen was toured on 10/26/22 at 11:00 am with Staff 2 (Administrator) and Staff 7 (Culinary Services Director). They acknowledged the above findings.

OAR 411-054-0300 (1)(a) Resident Services Meals, Food Sanitation Rules

1.     Kitchen flooring has been newly painted. Ceiling vents have been cleared of dust and debris. Patchy damaged walls have been repaired. Hole in dry storage ceiling  and above kitchen prep sink have been repaired. Fan affixed to far wall in café kitchen has been cleared of dust and debris.

2.     Executive Chef and/or designee will complete a 100% enviornmental audit to ensure all flooring, vents, walls, ceiling and fans are free of dust, debris and holes on a weekly basis for two weeks.

3.     Executive Chef and/or designee will conduct weekly kitchen audits, observe and note physical condition of kitchen. Executive Chef and/or designee will report repairs to Building Services Director and/or deignee. Executive Chef and/or designee will maintain and document a weekly cleaning schedule.

4.     Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

4. Resident 3 was admitted to the facility in 08/2017 with diagnoses including congestive heart failure.

Observations of the resident, interviews with staff and review of the resident's record were completed between 10/24/22 and 10/27/22.

Evaluations were not completed quarterly. The most recent evaluation was dated 06/21/22 and did not include the following updates:

* Increased assistance with ADL's;

* Use of a wheelchair when not in his/her apartment;

* Frequent safety checks; and

* Recent falls.

The need to ensure evaluations were completed quarterly and were reflective of the resident was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 10/27/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included weakness.

During the entrance conference on 10/24/22, staff reported the resident required hands-on assistance in most of ADL's.

Clinical record review during the survey revealed s/he was independent in grooming, toileting, evacuation status and use of the call light system.

Interviews with staff and Resident 2's evaluation, dated 07/13/22, revealed the current evaluation was not reflective of the resident's current status in the following areas:

* Dressing/undressing;

* Grooming/oral hygiene;

* Toileting;

* Ambulation/mobility status;

* Mood/behaviors;

* Ability to use a call light; and

* The resident's ability to evacuate..

The need to ensure the evaluation was reflective of Resident 2's current care needs was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 ( LPN/Health Services Director) on 10/26/22. They acknowledged the findings. No further information was provided.

3. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included Type II diabetes.

Observation of Resident 4, interviews with staff and review of the resident's clinical records revealed the resident's current evaluation was not reflective of the resident's current status in the following areas:

* Dressing/undressing;

* Toileting;

* Ambulation/mobility status;

* Housekeeping services;

* History of falls; and

* Medication management including insulin injections.

The need to ensure the evaluation was reflective of Resident 4's current care needs was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/26/22. They acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure resident move-in evaluations contained all required elements and failed to ensure quarterly evaluations were completed timely and reflective of current care needs, for 4 of 6  sampled residents (#s 2, 3, 4 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 09/2022 with diagnoses including atrial fibrillation. The move-in evaluation failed to address or was not reflective in the following areas:

* List of medications and PRN use;

* Visits to the health practitioner, hospital or nursing facility in the past year;

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

* Pain including non-pharmaeucutical interventions for pain; and

* Complex medication regimen.

The need to ensure move-in evaluations included all required components was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director) on 10/26/22. They acknowledged the findings.

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

1.Residents 2,3,4 and 5 evaluations were updated to reflect the resident's current level of functioning.

2.Resident move-in evaluation tool to be updated to include current required elements including: List of medications and PRN use; Visits to the health practitioner, hospital or nursing facility in the past year; Personality, including how the person copes with change and challenging situations; Pain including non-pharmaceutical interventions and complex medication regimen.

3.Resident quarterly evaluation timeframes have been reviewed and evaluations that were out of compliance have been completed reflecting the resident's current performance.

4.Quarterly evaluations will be completed by designated qualified staff member in conjunction with direct care staff provider who is knowledgeable of the resident's current status and by observation.

5.Administrator or designee will review quarterly evaluations weekly to assure compliance with accuracy and completeness.

2. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included dementia. Resident 2 was receiving hospice services as of the revisit survey.

Observations, staff interviews and review of the record during the survey revealed s/he was incontinent of bowel and bladder, was dependent on staff for ADL care, and had a hospital bed with bilateral side rails.

The most recent evaluation, dated 11/25/22, was not reflective of the resident's health status and current needs in the following areas:

* Sleeping habits;

* Toileting and bladder management;

* Bathing;

* Grooming;

* Mobility: assistive devices; and

* Pain: pharmaceutical interventions.

On 03/16/23 at 3:10 pm, the need to ensure Resident 2's evaluation was reflective of his/her health status and current needs was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director). They acknowledged the findings. No other information was shared.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were completed at least quarterly, corresponded with quarterly service plan updates, and were reflective of the resident's current status for 2 of 5 sampled residents (#s 2 and 12) whose evaluations were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 12 admitted to the facility in 08/2021 with diagnoses including cancer of the skin and blood.

The resident's quarterly evaluation, dated 03/01/23 and current service plan, dated 02/21/23 were reviewed. Staff 17 (Resident Assistant) was interviewed on 03/16/23 at 11:53 am.

The following elements on the evaluation were found to not correspond with Resident 12's quarterly service plan:

* Frequency of bathing;

* Bed making;

* Trash removal;

* Facility being responsible to wash the linens and towels;

* Recent losses;

* Depression; and

* Outside provider involvement.

The need to ensure the evaluation corresponded with quarterly service plan updates and was reflective of the resident's current health status was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 03/16/23. They acknowledged the findings.

C252

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

1.Residents 2 and 12's evaluations were updated to reflect the resident's current service needs and requests and correspond to the quarterly service plan.

2.All resident quarterly evaluation timeframes have been reviewed and evaluations that were out of compliance have been completed reflecting the resident's current service needs and requests. Dates for quarterly evaluation timeframes have been staggered to assure timely completion.

3.Health services director and community RN will review quarterly and change of condition evaluations weekly to assure compliance with accuracy and completeness.

4.Administrator will monitor performance and make appropriate adjustments through the QAPI process for three months and quarterly thereafter.

5. Resident 3 was admitted to the facility in 08/2017 with diagnoses including congestive heart failure.

Observations and interview with the resident, interviews with staff and review of the service plan dated 06/21/22, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Wheel chair use as needed;

* Increased assistance with ADL's;

* The need for frequent safety checks;

* Recent fall and interventions;

* Outside provider services; and

* Skin issue.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (Administrator) and Staff 5 (Health Services Director) on 10/27/22. They acknowledged the findings.

6. Resident 6 was admitted to the facility in August 2021 with diagnoses including chronic pain.

Observation and interview with the resident, interviews with staff and review of the service plan dated 10/17/22, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Use, safety and monitoring of siderails.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 10/27/22. They acknowledged the findings.

3. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included weakness.

During the entrance conference on 10/24/22, staff reported the resident required hands-on assistance in most of ADL's.

Clinical record review during the survey revealed s/he was independent in grooming, toileting, evacuation status and use of call light system.

A review of  Resident 2's service plan dated 07/13/22, Temporary Service Plans (TSPs)  and interviews with the staff, revealed the current service plan was not reflective of the resident's current status and did not provide clear instruction in the following areas:

* Dressing/undressing;

* Grooming/oral hygiene;

* Toileting;

* Ambulation/mobility status;

* Mood/behaviors;

* Ability to use a call light; and

* The resident's ability to evacuate.

The need to ensure the service plan was reflective of the resident's needs and provided clear instruction to staff was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/26/22. Staff acknowledged the findings.

4. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included Type II diabetes.

Observation of Resident 4, interviews with staff and a review of the resident's clinical records revealed the resident's current service plan was not reflective of the resident's current status and did not provide clear instruction in the following areas:

* Dressing/undressing;

* Toileting;

* Ambulation/mobility status;

* Housekeeping services;

* History of falls; and

* Medication management including insulin injection.

The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/26/22. They acknowledged the findings. No further information was provided.

2. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Parkinson's disease.

The resident's service plan dated 09/29/22, progress notes from 08/01/22 through 10/24/22, and hospice notes were reviewed. The resident and staff were interviewed during the survey. The service plan was not reflective and did not provide clear instruction to staff in the following areas:

* Hospice services and schedule;

* Staff instructions for when the resident does not have a private caregiver;

* Recent falls and interventions;

* Adaptive eating utensils; and

* Emergency evacuation ability.

The need to ensure resident service plans were reflective of current care needs and provided clear directions to staff was discussed with Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/27/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed upon move-in, updated within 30 days of move-in and at least quarterly thereafter, were reflective of residents' current health status and care needs and provided clear direction to staff regarding the delivery of services for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 09/2022 with diagnosis including a history of transient cerebral ischemic attack and hypertension.

1. Resident 5's initial service plan was not completed at the time of move-in, was not updated within 30 days of move-in and was not available to staff.

Review of "Visual/Bedside Individual Service Plan Report" (that was available to staff), interviews with staff and the resident, indicated the service plan report was not reflective of the resident's current health status and lacked clear direction to staff in the following areas:

* Knee pain and non pharmaceutical interventions for pain;

* Mobility and assistance with escorts to and from the dining room;

* Use of outside services; and

* Emergency evacuation assistance to include a wheelchair and one person assistance.

The need to ensure initial service plans were completed upon move-in, updated within 30 days of move-in, were reflective of current care needs and provided clear directions to staff was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director) on 10/26/22 at 4:00 pm. They acknowledged the findings.

OAR 411-054-036 (1-4) Service Plan: General

1.Residents #'s 1,2,3,4,5,6 service plans were updated to reflect residents' current health status, care needs and clear direction to staff regarding the delivery of services.

2.Upon move-in and completion of initial service plan, new resident will be placed in a 'tickler system' to remind designated staff to complete 30-day update.

3.Resident quarterly service plan timeframes have been reviewed and service plans that were out of compliance have been completed reflecting the resident's current performance.

4.Quarterly Service Plans will be completed by designated qualified staff member in conjunction with direct care staff provider who is knowledgeable of the resident's current status and by observation.

5.Quarterly Evaluations and Service Plans which are designed to be done in conjunction with each other will be put on a 'tickler system' to trigger initiation of quarterly reviews. (See C252)

6.Administrator or designee will review quarterly service plans weekly to assure compliance with accuracy and completeness.

7.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

2. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included dementia. Resident 2 was receiving hospice services as of the revisit survey.

Observations, staff interviews and review of the record during the survey revealed s/he was incontinent of bowel and bladder, was dependent on staff for ADL care, and had a hospital bed with bilateral side rails.

Resident 2's current service plan, dated 12/19/22, was not reflective or did not provide clear direction regarding the delivery of services in the following areas:

* Dressing assistance;

* Grooming;

* Bathing/showering;

* Mobility;

* Use of a hospital bed;

* Toileting/bladder/incontinence care;

* Life Enrichment; and

* Side rail use.

The need to ensure the service plan was reflective of Resident 2's current needs and provided clear direction to staff was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 03/16/23 at 3:10 pm. They acknowledged the service plan was not reflective in several areas and needed to be updated. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 2 and 11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 01/2023 with diagnoses including unspecified abnormalities of gait and mobility, glaucoma, and cerebral stroke syndrome.

Observations were made of the resident's care on 03/15/23. Interviews with the resident, staff and the resident's private caregiver were conducted. The current service plan, dated 03/13/23 was reviewed.

The resident's family purchased a hospital bed with quarter-length side rails and a private caregiver assisted resident with ADLs, personal hygiene, physical activities and personal errands Monday through Friday, from 8:30 am to 1:30 pm. Resident 11 needed assistance from the facility staff at all other hours.

Resident 11's service plan did not provide a clear description to staff regarding the delivery of services during the hours when the private caregiver was not on duty, and did not include instructions for staff as to how the side rails were to be used and monitored for safety.

The need to ensure the service plan provided clear instructions to staff during the hours when the resident's private caregiver was not on duty was reviewed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 03/16/23 at 1:50 pm. They acknowledged the findings.

C260

OAR 411-054-036 (1-4) Service Plan: General

1.Residents 2 and 11's service plans were updated to reflect residents' current health status, care needs, requests and clear direction to staff regarding the delivery of services.

2.All resident quarterly service plans will be put on a 'tickler system' to trigger initiation of quarterly service plan reviews. Dates for quarterly service plans have been staggered to assure timely completion. (Also see C252).

3.Health services director and/or community RN will review quarterly and change of condition service plans weekly for accuracy and completeness.

4.Administrator will monitor performance monthly and make appropriate adjustments through the QAPI process for three months and quarterly thereafter.

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 residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6).  Findings include, but are not limited to:

Resident 1, 2, 3, 4, 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.

The need to ensure service plans were developed by a Service Planning Team was discussed on 10/26/22 with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director). No further information was provided.

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

1.The facility has identified the Service Plan Team members for resident(s): 1,2,3,4,5,and 6 and will complete full evaluations of the residents to identify current status and update the resident's service plans with the resident(s) and their responsible parties(as applicable) and the Service plan team.  

2.All residents will have an evaluation of their current status and needs completed.  Their individual service plans will be updated as applicable based on the outcome of their current evaluation.

3.The facility has been inserviced by an outside RN Consultant as to the components of resident evaluation, service plan and required service plan team members for compliance.

4.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included Type II diabetes.

During the survey, s/he was identified as having short-term changes of condition regarding new medications and skin issues.

Clinical records, including progress notes from 08/01/22 to 10/24/22 and Resident Temporary Service Plans (TSPs) were reviewed.

The clinical record provided the following information:

* 08/15/22 - Returned from rehabilitation;

* 09/07/22 - "Bilateral pedal edema";

* 09/09/22 - New gout pain medication;

* 09/28/22 - "started on Effexor several days ago";

* 10/17/22 - Received Flu shot; and

* 10/20/22 - Received COVID booster shot.

There was no documented evidence that the resident's short-term changes of condition and skin status were monitored, at least weekly, to resolution.

On 10/26/22, the above findings were reviewed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director). Staff acknowledged findings.

Based on record review and interview, it was determined the facility failed to ensure short-term changes of condition were monitored and progress documented at least weekly through resolution, and the effectiveness of interventions was monitored for 2 of 6 sampled residents (#s 1 and 4) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Parkinson's disease.

Resident 1's current service plan, dated 09/29/22 noted s/he was a high risk for falls, required two-person assistance with escorts to meals and all activities and if the resident appeared tired, weak, or unsteady on his/her feet, staff were to offer him/her a place to sit down and rest. The service plan instructed staff to keep the resident's environment clean and free of clutter and ensure the resident had appropriate shoes or nonskid socks while walking; staff to perform safety checks on the resident at 10:30 am, 12:00 pm, 2:30 pm, 6:00 pm, and 10:00 pm.  

A review of the resident's record, including progress notes, temporary service plans, incident reports from 07/15/22 through 10/24/22, and staff interviews identified the resident experienced multiple injury and non-injury falls.

There was no documented evidence the facility consistently reviewed or monitored service plan interventions following each fall to determine if they were being provided and were effective or whether additional interventions were needed.

The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/27/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition Monitoring:

1.Residents number 1 will be evaluated for current mobility status and health care needs and to  include the review of existing temporary service plans ( see C 262) and  include a review of interventions related to fall, the effectiveness of those interventions and the addition of interventions as applicable based on evaluation. Resident number 4 will be evaluated for current status and healthcare needs to include a review of existing temporary service plans to determined those areas have been resolved, or if weekly documentation is to continue.  Documentation to resolution will be completed

2.All residents will be audited for active temporary service plans and evaluated if these temporary service plan areas are resolved. If, so, documentation of individual resident evaluations will be completed to resolve the Temporary Service Plan and update the permanent Service Plan as applicable.  If temporary Service Plans are still active, an evaluation will be completed of the individual resident to determine their current status and evaluation and documentation will be completed weekly and documented in the resident's clinical record until resolution.

3.The 24- hour Alert charting process policy and procedure will reviewed and appropriate staff in-serviced on the components of this policy and procedure to include continued evaluation and documentation of the resident status until any resident health status or need is resolved.

4.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

2. Resident 3 was admitted to the facility in 08/2017 with diagnoses including congestive heart failure.

Observations and interview with the resident, interviews with staff, a review of the current service plan with updates through 10/24/22, and review of the progress notes dated 07/22/22 through 10/24/22 indicated the following significant change of condition:

A progress note dated 07/22/22 included Resident 3 had "increased weakness and confusion ...is requiring assistance with most tasks ...will report seeing people in [his/her] room that are not there. Discussed Hospice services with family."

The service plan identified the resident used a walker for mobility. During interviews with Resident 3, interviews with staff and observations of the resident during the days of the survey, s/he was confirmed to use a wheelchair when going any distance other than in his/her apartment. This was a significant change of condition for the Resident.

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

During an interview on 10/27/22 at 11:20 am, Staff 5 (LPN/Health Services Director) acknowledged the lack of a documented RN assessment for the significant changes in condition.

The need to ensure documented RN assessments for significant changes in condition was shared with Staff 2 (Administrator) on 10/27/22. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure a Registered Nurse assessed, documented findings and developed interventions for 2 of 3 sampled residents (#s 3 and 4) who experienced a significant change of condition in ADLs and received a diagnosis of a fracture. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included Type II diabetes.

Observations of the resident from 10/24/22 to 10/26/22 revealed the resident required a walker for mobility.

During the survey, Staff 15 (Health Care Coordinator) and Staff 16 (MT) reported the resident had a fall approximately 2-3 months ago which resulted a hip fracture.

A 07/19/22 progress note indicated "resident sent to hospital and diagnosed with hip fracture..."

The new diagnosis of the hip fracture represented a significant change of condition for the resident.

On 10/26/22 at 2:37 pm, Staff 5 (LPN/Health Services Director) confirmed there was no RN assessment which included documented findings and a development of interventions for the significant change of condition.

The failure to conduct an RN assessment following a significant change in condition was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 on 10/26/22. They acknowledged the findings.

OAR 411-054-0045 (1) (a-f)(A)(C-F) Resident Health Services.

1.Resident's 3 and 4 will have an RN assessment completed to address significant changes of condition that have occurred.  The resident's service plan will be updated as applicable based on the outcome of the assessment with the resident and/or their responsible party ( as applicable)  and the Service Plan Team.

2.See C 262 and C270.  Through the facility resident updated evaluations being completed on all current resident's , any evaluations that results in a significant change of status will require an RN assessment to be completed as soon as this is determined.  

3.The facility RN will be inserviced by an outside RN nurse consultant on the requirements of RN assessment for significant change of condition. The Health Services team will also be inserviced regarding the requirement to notify the RN of a change in status initiating an RN assessment as required for both short term and long term changes in condition.

4.The Administrator and Health Services Director will monitor for resident changes in condition weekly through their facility stand up process.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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 4 of 4 sampled residents (#s 4, 8, 9 and 10) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2022 with diagnoses that included Type II diabetes.

During the acuity interview on 10/24/22, Resident 4 was identified as having self- administered insulin injections. However, a review of 10/01/22 - 10/24/22 MAR indicated staff administered the insulin injections to the resident.

A review of Resident 4's delegation documentation during the survey revealed the following:

a. The initial delegation for Staff 15 (Health Care Coordinator), Staff 21(MT) and Staff 22 (MT), completed by Staff 4 (RN) on 08/15/22, lacked documentation in the following areas:

* Date when nursing assessment of the resident was completed; and

* How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs.

b. Re-delegation for Staff 15, 21 and 22, completed by Staff 4 on 10/25/22, lacked documentation in the following areas:

* There was no RN assessment for the resident's condition to determine that the resident remained stable and predictable;

* There was no documented evidence that the staff had returned demonstration of competency to determine if staff remained safe to perform the task; and

* The initial delegation, Staff 4 had planned to re-delegate  Staff 15, 21 and 22 in two months. The re-delegation was completed on 10/25/22, during the survey, which should have been done no later than 10/15/22.

c. Staff 16 (MT) and Staff 19 (Health Care Coordinator) had signed on the MAR that they administered insulin injections to the resident on multiple occasions. However, there was no documented evidence Staff 16 and Staff 19 were delegated for Resident 4's insulin injections.

2. The 10/01/22 through 10/26/22 MARs for Residents 8, 9, and 10 were reviewed and identified the residents received insulin injections by multiple unlicensed staff.  

Review of the current delegation records for Residents 8, 9, and 10 reviewed on 10/26/22, indicated the facility RN failed to accurately document all required components in accordance with OSBN Administrative Rules for Staff 16, Staff 18 (Certified Med Aide), Staff 19, Staff 20 (HCC), Staff 21, Staff 22, Staff 23 (CNA), Staff 24 (Health Care Coordinator), and Staff 25 (RCC) including:

* A current nursing assessment and condition of the resident to determine if the resident's condition was stable and predictable;

* Individual observation/return demonstration of task to determine if the unlicensed staff remained capable and willing to safely perform the task; and

* A rationale for how frequently the  unlicensed staff  would be re-evaluated.

On 10/26/22, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (Heath Service Director/LPN). They acknowledged the above findings. The Surveyor requested a plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.

On 10/26/22 at 3:04 pm, a plan to address the delegation issue was received and approved by the the survey team.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (Administrator), Staff 4 and Staff 5 (LPN/Health Services Director) on 10/26/22. They acknowledged the findings.

OAR 411-054-0045 (1)(F)(b) RN Delegation and Teaching

1.Residents 4,8,9 and 10 have had insulin injections delegated to unlicensed facility staff per OSBN guidelines.

2.Facility wide audit has been conducted to identify any further tasks requiring RN delegation.  Tasks identified requiring delegations have been completed per OSBN guidelines. New orders will be reviewed during clinical by the RN or knowledgeable designee daily for delegate appropriate tasks and implemented ASAP. Tasks that cannot be delegated before administration is due will have a licensed nurse complete the task.

3.Administrator or designee will review new orders 3x/week for delegate appropriate tasks and assure a plan is in place for task to be carried out until appropriate delegation is carried out.

4.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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

1. Resident 1 was admitted to the facility in 11/2021 with diagnoses including Parkinson's disease.

Resident 1's 10/01/22 through 10/24/22 MAR and physician's orders were reviewed and identified Tamsulosin, (medication for treating symptoms of an enlarged prostate), administered twice daily. The MAR indicated to administer the mediation at breakfast and bedtime. The MAR lacked specific administration times for when unlicensed staff should administer the medication.

On 10/27/22, the need for the facility to provide clear instructions to unlicensed staff on the MAR was discussed with Staff 4 (RN) and Staff 5 (LPN/Health Services Director). They acknowledged the findings.

2. During the relicensure survey conducted 10/24/22 through 10/27/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective, based on deficiencies in the following areas:

C 282: RN Delegation and Teaching;

C 302: Systems: Tracking Controlled substances;

C 303: Systems: Medication and Treatment Orders;

C 310: Systems: Medication Administration;

C 325: Systems: Self administration of medications; and

C 330: Systems: Psychoactive Medications.

On 10/26/22, the above information was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director). They acknowledged the findings.

OAR 411-054-0055 (1) (a) Systems:  Medications and Treatments:

1.Resident 1 will have specific times determined and documented for Medication pass that is completed by unlicensed staff

2.An audit of the Medication Administration Records will be completed to assure that all designated times for medications to be passed are present

3.A review of the facilities Medication Pass policy and procedures will be completed and medication techs and licensed nurses will be inserviced regarding medication pass times to be completed per facility policy and/or physician order.

4.The Administrator and Health Services Director will review all new orders during the  facilities 24-hour report process to assure correct medication times are in place.  This will continue weekly for four weeks. Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (# 2) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2018 with diagnoses which included right femur fracture and pain in right hip.

Resident 2 had an order for Ativan 0.5 mg every two hours as needed for agitation and Oxycodone 5 mg every four hours as needed for pain.

a. Resident 2's Controlled Substance Disposition Logs and MARs, reviewed from 10/01/22 - 10/24/22, revealed three occasions, 10/08/22, 10/14/22 and 10/17/22, when staff signed on the drug disposition log that the medication was given. However, the MAR lacked documentation that the resident received the medication.

b. Staff documented on the Resident 2's MAR that they administered Ativan 0.5 mg on 10/07/22. However, the drug disposition log lacked documentation that the medication was dispensed.

The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 ( LPN/Health Services Director) on 10/26/22. They reviewed the documentation and acknowledged the discrepancies.

OAR 411-054-0055 (1) (e): Systems:

Tracking Controlled Substances:

1.Resident 1's medication administration record has been reviewed to determine which staff had inconsistencies in documentation standards regarding controlled substances. These individuals will have medication pass competencies completed to assure documentation standards are maintained per policy.

2.All residents that currently have orders for controlled substances will have their medication administration records and the controlled drug disposition log audited for any inconsistencies and appropriated on the spot education will be completed with applicable staff determined by the audit.

3.Med Techs will all be evaluated by medication pass competency testing to include appropriate and consistent documentation of controlled substances.

4.The Administrator and Health Services Director will monitor that all medication pass competencies are completed on all current Med Techs and licensed nurses  and any new Med techs or licensed nurses will receive medication pass competencies as part of their on the job orientation. Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

2. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included weakness.

Review of Resident 2's clinical records revealed the following:

Resident 2 was prescribed Hyoscyamine 0.125 mg every six hours for excess secretions.

Resident 2's 10/01/22 through 10/24/22 MAR indicated to administer the medication for upset stomach and the medication was administered to the resident on two occasions, 10/02/22 and 10/06/22 for upset stomach, not for excess secretions.

On 10/26/22, the physician's orders and the MARs were reviewed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director). Staff acknowledged the findings.

3. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included Type II diabetes.

During the survey, the resident's 10/01/22 - 10/24/22 MAR and physician orders were reviewed.

The MAR indicated the following:

* To administer Lantus (insulin to treat diabetes) 36 units subcutaneously daily;

* To check CBGs (blood sugar level) two times daily;

* To administer Bisacodyl suppository as needed;

* To administer Calcium Carbonate 500 mg every four hours as needed for "GI distress"; and

* To administer refresh eye drops two times daily as needed for dry eyes.

There were no physician orders for the above medications.

On 10/26/22, the physician's orders and the MARs were reviewed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director). Staff acknowledged the findings and no further documentation was provided prior to exit.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility is responsible to administer for 3 of 6 sampled residents (#s 2, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 5 moved into the facility in 09/2022 with diagnoses including hypertension.

Review of Resident 5's clinical record identified there was no documented evidence Resident 5's current physician orders were available in the facility record.

The need to ensure the facility had signed physician orders in the resident's chart was discussed with Staff 1 (Chief Executive Officer), Staff 2 (Administrator), Staff 3 (Medical Director), Staff 4 (RN), and Staff 5 (LPN/Health Services Director) on 10/26/22. They acknowledged the findings.

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

1.See C 302 regarding medication pass competencies to be completed on all Med Techs and Licensed nurses to include right resident, right medication, right reason for use,  right route,  right dose, right time.   Resident 5 has had updated signed physician orders obtained with the Residents medication administration records updated as applicable.  Resident 2 has had their medication for reduction of excess secretions audited to determine which staff are to be individually educated on following and carrying out orders and prescribed by the resident's physician.  These staff members will have individual in-servicing regarding the medication pass process.  Resident 4 has had updated physician orders obtained and the medication administration record has been updated as applicable.

2.All resident's medication administration records will be audited and each order verified with a current physician order.  Any residents with missing physician orders will have the resident's physician contacted and updated orders obtained.

3.The facility will audit all resident's clinical records monthly for three months then quarterly thereafter to assure that current physician orders are in place and match the current medication administration record.

4.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included medication-specific instructions, had specific parameters for PRN medications and accurate reason for use for 2 of 6 sampled residents (#s 2 and 4) whose MAR's were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 09/2018 with diagnoses which included a right femur fracture and pain in the right hip.

Review of the resident's 10/01/22 through 10/24/22 MAR and physician's orders revealed the following:

a. Resident 2 was prescribed two medications to treat pain:

* Oxycodone 5 mg every four hours as needed for pain; and

* Tramadol HCL 25 mg twice daily as needed for pain.

The PRN pain medications lacked clear parameters for when to administer and which one should be given first.

b. Resident 2 was prescribed Hyoscyamine 0.125 mg every six hours for excess secretions. The MAR indicated to administer the medication for an upset stomach. This represented an inaccurate reason for use on the MAR.

The need to ensure the MAR was accurate and included medication specific instruction and parameters for PRN medications was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/26/22. They reviewed the documentation and acknowledged the findings.

2. Resident 4 was admitted to the facility in 01/2022 with diagnoses which included chronic gout.

Review of the resident's 10/01/22 through 10/24/22 MAR and physician's orders revealed the following:

* ProAir HFA Aerosol inhaler 1- 2 puffs as needed for shortness of breath.

The multiple doses of the inhaler lacked clear parameters for when to administer 1 puff versus 2 puffs.

The need to ensure the MAR was accurate and included medication specific parameters for PRN medications was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Services Director) on 10/26/22. They reviewed the documentation and acknowledged the findings.

OAR 411-054-0055 (2) Medication Administration

1.See C 300, C 303:  Resident 2 and resident 4 have had their medication administration s reviewed for any medications that require specific parameters for use or when to administer which medication prior to another.

2.All Resident physician orders and medication administration records will be audited for the need for or clarification of parameters for medication administration

3.All med Techs and licensed nurses will be in-serviced on obtaining or following parameters for use. The following parameters during medication pass will also be included in the staff medication competency evaluation.

4.The Administrator and Health Services Director will monitor all new orders for clarification of need for parameters as applicable during the facilities 24- hour report process and all resident physician orders monthly for three months then quarterly thereafter. Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on 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 2 of 5 sampled residents (#s 4 and 11). This is a repeat citation. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 01/2022 and had diagnoses which included hypertension.

Resident 4's MARs, reviewed from 02/01/23 - 03/15/23, revealed the following inaccuracies:

* Staff were instructed to "hold blood pressure medications if systolic blood pressure [upper number] is less than 100 and/or heart rate is less than 50. Notify MD three times a day."  

According to the MARs, staff initialed three times a day that the BP and pulse had been taken. However, there was no documentation of the results.

In an interview on 03/16/23 at 2:10 pm, Staff 16 (MT) reviewed the MAR and stated staff were taking the BP and pulse three times a day, but not consistently documenting it.

Staff 28 and 29 (RNs) were interviewed on 03/16/23 at 2:30 pm. Both RNs reviewed the MAR and stated it was inaccurate. Staff 28 said she thought the order was discontinued but would verify with the physician.

On 03/16/23 at 3:10 pm, the need to ensure MARs were accurate was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director). They acknowledged the findings. No other information was shared.

2. Resident 11 was admitted to the facility in 01/2023 with diagnoses including low back pain and cerebella stroke syndrome.

Review of the resident's 03/01/23 through 03/15/23 MAR and physician's orders revealed the following:

a. Resident 11 was prescribed two medications to treat pain:

* Acetaminophen 500 mg every six hours as needed for pain; and

* Tramadol HCL 50 mg every eight hours as needed for moderate to severe pain.

The PRN pain medications lacked clear parameters relating to which medication should be given first.

b. Resident 11 was prescribed three medications to treat constipation:

* Milk of Magnesia 30 mgs as needed; and

* MiraLax power 17 grams every 12 hours as needed; and

* Bisacodyl suppository as needed if Milk of Magnesia was ineffective.

The PRN bowel medications lacked clear parameters for which medication should be administered first and how long should staff wait before administering the next bowel medication.

The need to ensure the MAR was accurate and included medication specific instruction and parameters for PRN medications was discussed with Staff 2 (Administrator) and Staff 5 (LPN/Health Services Director) on 03/16/23. They acknowledged the findings.

C310

OAR 411-054-0055 (2) Medication Administration

1.Resident 4 and 11 have had their medication administration records reviewed and corrections made for medications requiring specific parameters for use or when to administer which medication prior to another.

2.All resident medication and treatment administration records will be audited for the need for, or clarification of, parameters for medication administration. Where to look for and how to follow parameters during medication passes will be included in the health care coordinator medication competency evaluation.

3.The health services director and/or community RN will monitor all new orders for clarification of need for parameters as applicable during the facilities 24- hour report and 90-day order review process.

4.Administrator will monitor monthly and make appropriate adjustments through the QAPI process for three months and quarterly thereafter.

Based on interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer medications for 1 of 2 sampled residents (# 4) who self-administered hormone cream. Findings include, but are not limited to:

Resident 4's 10/01/22 - 10/24/22 MAR indicated the resident self-administered Estradiol cream one time a day on Monday and Friday to treat urinary incontinence.

A review of Resident 4's clinical records revealed the following:

There was no current documented evidence the facility evaluated Resident 4's ability to safely self-administered the hormone cream. The last evaluation for the resident's ability to safely self-administered the hormone cream was on 02/10/22.

On 10/26/22 at 2:50 pm, Staff 5 (LPN/Health Service Director) confirmed there was no current evaluation related to the self-administration of the cream.

The need to complete evaluations of a resident's ability to self administer medications initially and at least quarterly was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 on 10/26/22. They reviewed the documentation and acknowledged the findings.

OAR 411-054-0055 (5) Systems:  Self-Administration of Meds:

1.Resident 1 has had an RN assessment of self-administration of medication ability completed.

2.All resident's physician order's and medication administration records will be audited to determine who had orders to self- administer their medications.  Each of those that are found to have such orders will also have their clinical records audited for an RN self- administration assessment.  If one is not present, then an RN assessment will be completed and a re-evaluation will be completed quarterly thereafter.

3.The Healthcare Coordinator, and RCC's will be in-serviced to be aware of orders that state may self - administer any medication including OTC's.  The facility will then alert the facility RN to complete an RN resident self-administration of medication assessment.  This assessment will be completed initial and quarterly to determine the residents on-going ability to safely administer medications per self.

4.The Administrator and Health Services Director will monitor monthly for three months and then quarterly thereafter for performance. Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (# 2) who received psychotropic medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2018 with diagnoses which included right femur fracture and pain in right hip.

The resident's 10/01/22 through 10/24/22 MARs were reviewed and the following was noted:

Resident 2 was prescribed Ativan 0.5 mg every two hours as needed for agitation.

The MAR indicated Ativan was administered on 10/01/22, 10/07/22, 10/11/22 and 10/13/22.

The facility lacked documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration of Ativan.

During an interview on 10/26/22, Staff 15 (Health Care Coordinator) confirmed there was no documented evidence that non-pharmacological interventions were attempted and ineffective prior to administering the medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications was discussed with Staff 2 (Administrator), Staff 4 (RN) and Staff 5 (LPN/Health Service Director) on 10/26/22. They acknowledged the findings.

OAR 411-054-0055(6): Systems:  Psychotropic Medication:

1.Resident 2 has had their medication administration record reviewed for psychotropic medication use.  Behaviors associated with the medication use have been reviewed with direct care staff and discussion with direct care staff and the resident to determine what non-pharmacological interventions would be helpful prior to the administration of a psychotropic medication. The medication administration record and service plan will be updated with the interventions determined to be attempted prior to administering the psychotropic medication.

2.All physician orders and medication administration records will be audited to determine if all PRN ( as needed) psychoactive medications have non-pharmacological interventions in place to utilize prior to administering an psychoactive medication.  Those determined to not have non-pharmacological interventions in place will have them obtained. Service plans will be updated as applicable.

3.All Med Techs, RCC, Healthcare Coordinator, and licensed nurses will be in-serviced on the requirement to utilize or obtain non-pharmacological interventions for all PRN psychoactive medications prior to administration and the need to update service plans as applicable.

4.The Administrator and Health Services Director will monitor all new orders weekly, all existing medication administration records monthly and then quarterly thereafter for non-pharmacological interventions and performance with this process.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

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

On 10/24/22, Staff 2 (Administrator) was asked to provide evidence the facility had implemented an ABST to determine appropriate staffing levels for the facility. Staff 2 stated the facility had not completed an ABST assessment for each resident.

There was no documented evidence the facility was using an ABST which would determine a staffing plan to meet the 24-hour scheduled and unscheduled needs of residents.

During the survey, there were no concerns of the facility having inadequate staff.

The requirements of the ABST were discussed with Staff 2 and Staff 5 (LPN/Health Services Director) on 10/24/22. They acknowledged the findings.   

OAR 411-054-0037 (1-8) Acuity Based Staffing Tool:

1.The facility has participated in the recent State of Oregon DHS Acuity Based Staffing Tool training.  They have the Acuity Based Staffing Tool and have signed into the system. The facility will be completing the tool as they are evaluating and updating all residents and their service plans to include all 22 areas in the OAR to be evaluated to determine the appropriate number of staff based on the acuity time outcome.

2.The facility will continue to evaluate each resident until all residents evaluations and updated service plans are completed and include all the areas of the acuity based focus areas.

3.Staff have been educated through the States DHS zoom training and are in the process of completing the Acuity Based Staffing tool.

4.The Administrator and/or designee and the Health Services Director and/or designee will be completing and monitoring the process until fully implemented and will update quarterly individual resident acuity with quarterly service plan evaluations and updates as applicable.  Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 9, 10, 12, and 13) completed all components of pre-service orientation and completed dementia training as required prior to beginning job responsibilities, and two of two long-term staff (#s 11 and 14) completed all required components of infectious disease prevention training by 07/01/22.

Staff training records were reviewed on 10/25/22 and revealed the following:

1. There was no documented evidence Staff 9 (Resident Assistant), Staff 10 (Resident Assistant), Staff 12 (Server), and Staff 13 (Server), hired on 08/19/22, 09/02/22, 09/28/22, and 10/14/22 respectively, completed all required pre-service orientation topics prior to beginning job duties, including:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 9, Staff 10, Staff 12, and Staff 13 completed pre-service dementia training prior to providing care to residents that included all of the following topics:

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

* Techniques for understanding, communicating, and responding to behaviors; 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.

3. There was no documented evidence Staff 11 (Resident Assistant) and Staff 14 (Dish Person), hired 08/23/21 and 06/09/21, respectively, completed infectious disease prevention training by 07/01/22 as required.

The need to ensure newly hired direct care staff completed all pre-service orientation topics and pre-service dementia training prior to beginning any job responsibilities and long-term staff completed all required infectious disease prevention training was discussed with Staff 2 (Administrator). She acknowledged the findings.

OAR 411-054-0700 (3-4) Staffing Requirements and Training: Caregiver Requirements

1.Staff 9, 10, 12,13, and 14 have completed all components of pre-service orientation, training education.

2.Human Resources will complete the following: audit of employee files for completion of pre-service orientation, training, and education, and all new hire documents. Additional staff identified will complete all components of pre-service orientation, training, and education before starting job duties. Human Resources to inservice hiring managers on hiring process, including not starting employees until HR has confirmed all pre-service orientation, training, and education complete.

3.Human Resources Director or designee will conduct monthly audit on 100% of new hires, including documents, pre-service  orientation, training, and education.

4.Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to verify and document that 2 of 2 newly hired direct-care staff (#s 9 and 10) demonstrated satisfactory performance in any duty they were assigned to within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 10/26/22 revealed the following:

Staff 9 (Resident Assistant) and Staff 10 (Resident Assistant), hired on 08/19/22 and 09/02/22, respectively, lacked documented evidence of competency demonstration for assigned caregiving duties within 30 days of hire date.

The need to ensure staff had documented evidence of competency demonstration in assigned duties within 30 days of their hire date was discussed with Staff 2 (Administrator) on 10/27/22. She acknowledged the findings and said she would address the deficiencies.

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

1. The facility is completing all training requirements for all staff mentioned in the survey under both C 320 and C 372.

2.The Administrator, and RN Nurse Consultant met with the Human Resources department and reviewed all the trainings that are required of all staff and Direct Care staff for pre-service, 30 day training, annual training and the newly updated infection control disease prevention.  A discussion with DHS was completed and the current infection control disease prevention through relias was approved for use.  The OARs regarding training requirements were reviewed and a spread sheet developed  to monitor for training completion and compliance of all current staff.  

3.The facilities staff training policies were reviewed and inservices to all facility department managers regarding the completion of presevice training, 30 day training of direct care staff and annual training of both direct and non- direct care staff was included. A training schedule was sent out to all managers and staff for completion of all trainings that were not present at the time of this survey. Newly hired staff will not be able to be assigned to their respective job until pre-service training is completed and approved by the facility Administrator or designee.

4.The Administrator, Human Resources Director and the Health Services Director will monitor weekly for training compliance for four weeks.  Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to ensure documentation of all required components on the fire drill record, staff knew the designated point of safety, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire and Life Safety records from 04/24/22 to 10/24/22 were reviewed on 10/26/22. The following deficiencies were identified:

1. The fire drill records did not include the following required information:

* Escape route used;

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

* Number of occupants evacuated.

2. Three staff interviewed lacked knowledge of the designated point of safety.

3. There was no documented evidence the facility provided fire and life safety instruction to staff on alternating months from fire drills.

The need to ensure documentation of all required components was on the fire drill record, staff knew the designated point of safety, and fire and life safety instruction to staff was provided on alternate months of the fire drill was discussed with Staff 2 (Administrator) and Staff 6 on 10/26/22. They acknowledged the findings.

OAR 411-054-0900 (1-2) Fire and Life Safety: Safety

1.      Fire drill document reviewed and updated to reflect all required components. Staff have been educated on designated point of safety. Fire and life safety training on alternating months from fire drills has been initiated. A fire drill record including all required components has been implemented.

2.     Human Resources will assign fire and life safety training to each staff member through our Relias training platform in alternating months from fire drills. Documentation of training will be kept in employee files. Fire drill document reviewed, updated, and implemented to reflect all required components. Documentation will be completed in months when fire drills are conducted. Documentation will be kept in the fire drill documentation binder.

3.     Building Services Director/Administrator will audit fire and life safety binder quarterly to monitor that fire drills are completed in accordance with rule. Human Resources Director or designee will audit employee trainings quarterly to monitor that training on alternate months of fire drill is being completed.

4.     Building Services Director and Human Resources Director will submit trainings of drills/training to Administrator monthly for review ongoing. Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.

Based on interview and record review, it was determined the facility failed to have a system for re-instructing residents, at least annually, in fire safety topics. Findings include, but are not limited to:

On 10/25/22 at 2:20 pm, Staff 2 (Administrator) and Staff 6 (Building Services Director) reported a new resident was given a copy of the facility's fire safety procedures; however they acknowledged residents were not re-instructed on fire safety topics, at least annually.

The need to ensure residents were re-instructed about the facility's fire and life safety procedures at least annually and to keep a written record of fire safety training was discussed with Staff 2 and Staff 6. They acknowledged the findings.

OAR 411-054-0900 (5) Fire and Life Safety: Training for Residents

1.     Residents have been re-instructed regarding facility's fire and life safety procedures.

2.     All residents will be re-instructed regarding facility's fire and life safety at annual safety meeting and document in fire life saftey binder. New residents will be instructed at move-in and annually thereafter.

3.     The Administrator and or designee and Building Services Director and/or designee will audit fire life safety binder annually to  ensure 100% of residents have been re-instructed on facility's fire and life safety training

4.     Results of annual audit will be reported to the QAPI committee by the Building Services Director and/or designee.  

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

Refer to C252, C260 and C310.

OAR 411-054-0105 (2-8)

1.Please refer to C252, C260 and C310

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:

The exterior grounds were toured on 10/24/22. There were drop-offs of up to three inches from the sidewalk to the planting beds at the corners of multiple pathways in the ALF courtyards. These drop-offs created potential tripping or fall hazards for residents.

On 10/25/22 at 1:30 pm the surveyor showed Staff 2 (Administrator) and Staff 6 (Building Services Director) the drop-offs in the ALF courtyards. They acknowledged the drop-offs.

OAR 411-054-0300 (3)(a-h) General Building Exterior

1.     Drop-offs from sidewalks in outdoor courtyard area and planting beds have been have been filled with mulch and soil to be flush with sidewalk.

2.     Building Services Director and/or designee will complete 100% exterior pathways audit and make repairs as appropriate.

3.     The Administrator and/or designee and Building Services Director and/or designee will conduct monthly audits of exterior pathways, observe and note physical condition of common-use pathways, and make repairs as appropriate.

4.    Facility will monitor performance and make appropriate adjustments through the QAPI process for three months until substantial compliance is met and then quarterly thereafter.