Print Inspection: FQ9K

The findings of the re-licensure survey, conducted 03/16/22 through 03/18/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/18/22, conducted 08/23/22 through 08/24/22, 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 kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 03/16/22 at 9:28 am, the facility's kitchen was observed to need cleaning or repair in the following areas:

* Floors throughout the kitchen, including dry storage, walk-in refrigerator, freezer, and underneath the beverage station had black matter build-up and food debris in corners, around perimeter edges, under equipment, and inside floor drains;

* Flooring that ran up the walls to form baseboard was pulling away from the wall in multiple areas and had large cracks in the flooring;

* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, white/gray accumulation, dust and/or debris;

* Wood shelving near the ice machine had missing laminate to the edges, exposed wood, and spills on the shelves;

* Ceiling vents had an accumulation of lint and dust on the grates;

* Ceiling lights in the dry storage and near the steam table were cracked and had broken or missing pieces;

* A section of the wall in the back corner of the dry storage was pulling apart, with a large crack and a small open hole;

* The grease drain on the cook top was packed full of debris and accumulated grease, and the grease trap underneath was full of debris;

* Flooring throughout the kitchen, dishwashing area, and dry storage had dings, black discoloration, and deep gouges. Missing chunks of flooring were noted in the dry storage, dishwashing room and around a drain in the prep area;

* Doors, door frames, and walls had large splatters, spills, chips, missing plaster and dings; and

* The microwave had food debris and spills in the interior and along the door.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (Executive Director), Staff 8 (Sous Chef), and Staff 21 (Sous Chef) on 03/16/22. The staff acknowledged the findings.

1. *Floors throughout the entire kitchen, including dry storage, walk-in refrigerator, freezer, dishwashing room, baseboard wall junctions and around all drains; has been approved for repair or replacement by our Regional Maintenance Tech and we are awaiting on bids and completion date.

* All the wood shelving in the kitchen including damaged section near ice machine is to be replaced with stainless steel; as approved by our Regional Maintenance Tech and we are awaiting on bids and completion date.

*Both the wall in the back corner of dry storage with large crack and small open hole; and walls, doors and door frames with spills, chips, missing plaster and dings; Ceiling lights that are cracked, broken, or missing pieces will be repaired in house by Maintenance Tech no later than 04/30/2022

2. All the areas in the kitchen needing cleaning including; underneath the equipment and around the beverage station, all floor drains, all the shelving throughout the kitchen including all food contact areas, ceiling vents, grease drain on cook top, and microwave; will be detailed during an all hands cleaning party on 04/08/2022. This all hands cleaning party will also be auditing for any additional areas in need or cleaning and/or repair.

3.In prevention of reoccurrence of this violation; a comprehensive weekly cleaning list with daily tasks encompassing the fore mentioned discrepancies and critical cleaning tasks will be implemented and monitored by the Dining Services Director starting on 04/10/2022 and monitored weekly thereafter.

4. The Executive Director and the Dining Services Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure service plans provided clear directions to caregiving staff regarding the delivery of services for 1 of 3 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

During the entrance conference on 03/16/22, Resident 1 was identified to receive services from hospice.

Resident 1's service plan, dated 03/14/22,  indicated the resident was on hospice; however, the service plan lacked clear instructions to caregiving staff regarding what services hospice provided, frequency of visits, and responsibilities.

During interviews on 03/16/22, Witness 1 and 2 (Family Members) indicated care staff were unaware of their roles and responsibilities related to hospice care.

The need to ensure service plans provided clear directions to staff  regarding the delivery of services was discussed with Staff 5 (Health and Wellness Director) on 03/17/22. She acknowledged the findings and indicated she would plan staff training on hospice services.

1. Resident #1 passed away on hospice.

2. Records of remaining residents who receive hospice services were reviewed and service plans modified to be clear what services hospice provides. In addition, current resident service plans will be reviewed and updated as necessary to assure they are reflective of needs. The Executive Director and Health and Wellness Director have reviewed rule and community policy as it relates to the service planning process.

3. The Executive Director or designee will conduct random audits of resident service plans twice monthly for 60 days.

4. The Executive Director, and Health and Wellness Director are responsible for this plan of correction.

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 3 of 3 sampled residents (#s 1, 2 and 4) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1, 2 and 4's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 03/18/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 4 (RN) and Staff 5 (Health and Wellness Director). They acknowledged the findings.

1.Resident #1 passed away on hospice. Resident #2 and #4 have had care conferences with the resident and/or family members and service plans have been signed and/or sent out for signature.

2.A service planning team has been assembled and the Executive Director has created a schedule to ensure all service plans are reviewed with residents and their family members.  Care conference meetings will be scheduled on a weekly basis to assure service plans are reviewed per regulatory requirements.

3.The Executive Director or designee will conduct random audits of resident service plans twice monthly for 60 days.

4.  The Executive Director is responsible for this plan of correction

Based on interview and record review, it was determined the facility failed to evaluate and monitor service-planned interventions for 1 of 3 sampled residents (#1) who experienced short-term changes of condition related to falls. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2015 with diagnoses including Parkinson's disease.

A review of the resident's progress notes, service plan, incident reports, and temporary service plans (TSP) indicated Resident 1 was a high fall risk and experienced five falls on the following dates:  

* 12/22/21 - The resident had an unwitnessed fall and was found on the floor in his/her room. An incident report indicated, "Call don't fall signs had been placed in the resident's room and bathroom to help remind the resident to call before self-transferring";

* 01/12/22 - The resident fell from his/her wheelchair and sustained a bump on the head and a skin tear to the left elbow. An incident report noted the resident was encouraged to use a new grabber he/she got to pick things up off the ground. A TSP instructed staff to "remind resident not to reach for items on the floor and ask for help";

* 01/30/22 - The resident had an unwitnessed fall with injury and was found lying in his/her doorway between the living room and bedroom. Staff documented resident had a skin tear to the right elbow. A TSP instructed staff to "remind resident not to reach for things on the floor, check on resident frequently, keep an eye on wheelchair cushions, they slide around easily causing him/her to slide out of chair";

* 02/04/22 - The resident had an unwitnessed fall and was found on the floor next to his/her bed. A TSP instructed staff to "remind the resident to call staff before getting in and out of bed"; and

* 02/09/22 - The resident had an unwitnessed fall and was found on the floor next to his/her refrigerator door. Staff documented resident had bruising, redness, and swelling on his/her right side of body. A TSP instructed staff to conduct "hourly checks especially between 7-10 pm."

There was no documented evidence the facility had monitored previous fall interventions for effectiveness or thoroughly investigated to ensure staff were following the interventions after each fall.  

Monitoring effectiveness of interventions to ensure they were appropriate and continued to be effective was discussed with Staff 1 (Executive Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 03/18/22. They acknowledged the findings.

1. The record of Resident #1 has been reviewed and fall risk/pattern has been evaluated with interventions reflective on the service plan.

2.A Clinical meeting will be held 3-5 times weekly.  Residents with falls, skin issues and other identified changes in condition will be reviewed during the clinical meeting.  Discussion will take place to assure interventions are developed while considering previous interventions already in place, appropriate updates are made to the service plan and documentation is reflected in the resident record..  Staff will be trained on falls management policy to include following interventions outlined in the temporary service plan.

3.  The Executive Director, Health & Wellness Director and/or designee will randomly audit resident records weekly for 60 days to assure ongoing compliance.

4.  Executive Director and Health & Wellness Director will be responsible for this plan of correction.1.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medication for 1 of 3 sampled residents (#4) who were prescribed psychotropic medications. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 11/2021, with diagnoses including depression and dementia.

The resident's 03/01/22 through 03/16/22 MARs, signed physician orders, and progress notes dated 12/15/22 through 03/15/22 were reviewed, and staff were interviewed. The following was identified:

* Resident 4 had a physician order for Alprazolam (an anti-anxiety medication) 0.25 mg, 0.5 tablet every 12 hours as needed for anxiety.

* Between 12/15/21 and 02/23/22 staff administered Alprazolam to the resident 59 times.

* There was no documented evidence staff attempted non-drug interventions without success prior to administering the PRN anxiety medication.

On 03/16/22 Staff 5 (Health & Wellness Director) was interviewed and stated staff should be documenting non-pharmaceutical interventions in the resident's progress notes.

Staff 11 (Scheduler), in an interview on 03/17/22, reported she attempted non-drug interventions when Resident 4 was exhibiting symptoms of anxiety. She indicated she had not been documenting the interventions in the resident's progress notes.

The need to document non-pharmaceutical interventions which were unsuccessful prior to administering a PRN psychotropic medication was discussed with Staff 1 (Executive Director) and Staff 5 (Health & Wellness Director) on 03/17/21. They acknowledged the findings.

1.Staff education was completed immediately following discovery of no non pharmacological interventions being documented. Signs were posted and the staff on shift were trained on proper protocols. A Medication Technician meeting was also held on _3/24/22____ and all Medication Technicians were educated on the protocol of documenting non pharmacological interventions prior to administering as needed psychotropic medications.

2. Documentation of as needed psychotropic medication administration will be reviewed during the clinical meeting 3-5 times per week to ensure documentation of non-pharmacological interventions are placed in the record.

3.  Executive Director, Health & Wellness Director and/or designee will conduct random eMAR audits weekly for 60 days to monitor for compliance.

4.  Executive Director and Health & Wellness Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 10, 13 and 15) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 03/17/22.

There was no documented evidence Staff 10 (Med Tech), Staff 13 (Caregiver), and Staff 15 (Caregiver), hired 01/03/22, 12/31/21, and 01/25/22, respectively, had completed any of the required competencies within 30 days of hire. In addition, there was no documented evidence Staff 10 had demonstrated competence in the duties of  a medication technician prior to administering medication independently.

Staff 1 (Executive Director) was informed Staff 10 could not be scheduled to work as a medication technician until s/he had demonstrated competency in medication administration duties.

The need for staff to demonstrate competency in their job duties within 30 days of hire, including additional duties such as medication administration, was discussed with Staff 1 (Executive Director) and Staff 5 (Health & Wellness Director) on 03/17/22. They acknowledged the findings.

1. Current staff identified in survey, received competency training from 3/18-3/21 and were not scheduled to work independently until competency training and return demonstration was completed.

2. An audit was conducted to identify any areas other associates who were missing their competency training. Competencies were completed for all staff in need of this training from 3/18-3/21.

3.  Our Business Office Coordinator will partner with the Resident Care Coordinator to ensure that all competencies training is completed prior to associates being scheduled to work independently. This training requires validation of understanding through signatures of both the trainer and the new associate. Documentation of this training will be kept in the training binder.  Once the competencies are completed the new associates will review their training once more with the Resident Care Coordinator to ensure they fully understand the competencies and are properly trained to be independent.  New Medication Technicians will also receive this training as a caregiver prior to training in the med room, allowing them time to know each resident fully and their individualized care plans. Medication Techs will then have additional competencies to learn as they train with a designated Medication Tech trainer and documentation will be kept in the training binder as well.

4.Our Business Office Manager, Resident Care Coordinator and Executive Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 long-term staff (#s 9 and 12) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 03/17/22.

There was no documented evidence Staff 9 (Caregiver), hired 08/01/08, and Staff 12 (Caregiver), hired 10/17/17, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Executive Director) and Staff 5 (Health & Wellness Director) on 03/17/22. They acknowledged the findings.

1. An audit was conducted and a list of required annual courses was provided to each staff member on ___4/8/22____

2. Associates will have the opportunity to complete their annual course requirements during the monthly all staff meeting and independently through the online training system.

3. The Business Office Manager will maintain attendance records and provide bi-weekly updates to each department head to notify associates who have not completed their monthly training. Associates who have not completed their training thorugh either the monthly all staff or via the online system will be scheduled for designated training hours.

4. The Business Office Manager and the Executive Director are responsible for this plan of correction.  

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

Observations of the facility on 03/16/22 showed the following areas in need of cleaning or repair:

* There were spills and debris on cupboard shelves and inside drawers, and chipped cabinet doors in the dining room;

* Rubber transitions in the dining room floor were separating in multiple sections with debris and black accumulation gathered in the openings;

* Black, brown, and red stains of varying sizes were noted at the entrance to the dining room, near room 106, near room 110, near room 205, and near room 229. The carpet was frayed or lifting near room 204 and by the first floor sprinkler room;

* Multiple gouges and a long scratch were noted to the wood laminate flooring in the upstairs hallway, nearest the stairway;

* Room 107 had multiple large, dark stains near the bed, and room 209 had multiple black stains of varying sizes under and around the dining room table. A hole in the wall was noted near room 221;

* Doors to rooms 201, 217, 218, 221, and 228 had significant deep scratches, dings, and black streaking;

* Multiple benches in the halls on the first and second floor had dark spills/stains on the seats;

* Spills, splatters, and dust accumulation were noted on multiple walls throughout the facility halls and in the dining room;

* The oven located in the activity area had black spills and debris in the bottom of the oven. Cabinets and shelves in the activity area were chipped, scraped, and had spills/debris.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) on 03/16/22. She acknowledged the findings.

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

Observations of the facility on 03/16/22 showed the following areas in need of cleaning or repair:

* There were spills and debris on cupboard shelves and inside drawers, and chipped cabinet doors in the dining room;

* Rubber transitions in the dining room floor were separating in multiple sections with debris and black accumulation gathered in the openings;

* Black, brown, and red stains of varying sizes were noted at the entrance to the dining room, near room 106, near room 110, near room 205, and near room 229. The carpet was frayed or lifting near room 204 and by the first floor sprinkler room;

* Multiple gouges and a long scratch were noted to the wood laminate flooring in the upstairs hallway, nearest the stairway;

* Room 107 had multiple large, dark stains near the bed, and room 209 had multiple black stains of varying sizes under and around the dining room table. A hole in the wall was noted near room 221;

* Doors to rooms 201, 217, 218, 221, and 228 had significant deep scratches, dings, and black streaking;

* Multiple benches in the halls on the first and second floor had dark spills/stains on the seats;

* Spills, splatters, and dust accumulation were noted on multiple walls throughout the facility halls and in the dining room;

* The oven located in the activity area had black spills and debris in the bottom of the oven. Cabinets and shelves in the activity area were chipped, scraped, and had spills/debris.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Executive Director) on 03/16/22. She acknowledged the findings.