Print Inspection: H7UE

The findings of the relicensure survey conducted 03/18/24 through 03/21/24 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

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

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

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

The facility put immediate plans of correction in place during the survey and the situations were abated.

The findings of the first revisit to the relicensure survey of 03/21/24 conducted 07/01/24 through 07/03/24 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 03/21/24, conducted 08/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the licensee failed to ensure adequate administrative oversight of facility operations and supervision, and training of staff, which posed a risk to the safety of residents. Findings include, but are not limited to:

During the relicensure survey, conducted 03/18/24 through 03/21/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the severity and number of citations.

1. Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

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

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

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

The facility put immediate plans of correction in place during the survey and the situations were abated.   

2. Refer to deficiencies in the report.

ED will educate all managers on this POC and their responsibilities in this POC by 3/28/2024

ED is responsible for daily follow up at stand up with items on this POC

ED will develop and implement a weekend manager on duty schedule

ED will be educated by the RDO, RDHS, and VP Clinical Services on expectations of weekend MOD

ED will educate leadership team on expectations of weekend MOD

Based on observation, interview, and record review, it was determined the facility failed to ensure residents received services in a manner that protected privacy, respect and dignity in a homelike environment for 1 of 4 sampled residents (#1) during meal service, and multiple unsampled residents. Findings include, but are not limited to:

1. During the survey, multiple staff were observed on several occasions to communicate with staff with their language (non-English) and laugh while escorting residents to the dining room and/or to the TV area.

The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia. Observations and interviews with staff during the survey identified s/he relied on staff for incontinence care needs.

On 03/21/24 at 8:44 am, the surveyor observed Staff 10 (CG) assist Resident 1 in wheelchair into the dining area where other residents and staff were present. Resident 1 was without pants, shoes, or socks and was wearing a sweatshirt and incontinence briefs. Surveyor requested Staff 10 to assist Resident 1 with dressing to include pants, socks and shoes, which was performed.

The need to ensure residents were treated with dignity and respect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings

b. On 03/18/24 observed staff on two separate occasions escort unsampled residents into each of their bathrooms, the staff exited while the residents remained alone in their bathroom. The door to their rooms and bathrooms were left ajar. Another unsampled resident wandered into one of the open rooms and stood by the bathroom door while the resident was using the bathroom. One minute later a caregiver found the resident and escorted him/her out of the room.

c. During lunch service on 03/18/24 and beginning of lunch on 03/19/24, multiple caregivers were observed standing over residents while assisting with meals, not providing a dignified dining experience.

d. On 03/20/24, the surveyor overheard Staff 2 (Assistant ED) requesting a key be made for a resident per the family member's request. Staff 3 (Maintenance Director) stated the key would be a master key and Staff 2 confirmed that would be fine.

On 3/21/24, with the permission of a resident's family member who resided in Flower house, the survey team observed that this resident's key unlocked multiple separate resident units in Flower. Staff 18 (CG) confirmed that one key will get into all of the units in Flower. The same key was used to try and open resident units in a different house, River, and confirmed the key was not able to unlock the resident doors.

The need to ensure residents were treated with dignity and respect, and their privacy was protected, was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

3a. On 03/19/24 at 12:25 pm, during lunch service, an unsampled resident was sitting with three other people who self-identified as the resident's family. At that time, the resident was served a "veggie meal", did not have eating utensils, and the family requested additional food to be provided for the resident. The resident began eating with his/her hands. The family requested eating utensils from the staff. When the utensils were provided, the resident began eating with the utensils provided. Over a 45-minute period, the family requested additional food to be provided on three separate occasions before food was provided to the resident.

All staff will be educated by the ED/AED/RN/Designee on resident rights and dignity, including language,dignity with dining, and privacy/dignity with cares.

Resident key was replaced with a key specifically for that door.

ED will create and implement a manager on duty schedule for dining.

All staff will receive this education at time of hire, and at a minimum annually.

3. Resident 2 was moved into the facility in 01/2022 with diagnoses including dementia.

Observations of the resident from 03/18/24 to 03/21/24 revealed the resident required staff assistance with incontinent care and meal assistance.

Progress notes and incident reports dated 12/02/23 through 03/17/24 indicated the following:

* On 12/13/23 staff documented the resident had a fall at 8:00 am in dining room. S/he was sitting at the dining table while staff was getting breakfast ready and had redness, bruising and swelling to left side of face;

* On 02/06/24 the resident had an unwitnessed fall at 2:25 am in the room, getting out of bed; and

* On 03/14/24 the resident had an unwitnessed fall at 9:00 am in the room, with a large, raised skin area on the left forehead.

12/08/23 Temporary service plan indicated "staff to provide 1:1 feeding support for all meals and snacks."

The 02/22/24 service plan and Temporary service plan showed staff to check two times per shift safety checks and assisted to get the resident "up around 7-8 am".

There was no documented evidence the facility conducted an investigation to reasonably conclude the above incidents were not the result of abuse or neglect due to the possibility of not receiving morning care timely and safety checks as outlined on the service plan.

During an interview on 03/21/24, Staff 1 (ED) confirmed she had not reported the above incidents to the local unit. The need to investigate incidents of suspected abuse or neglect care and to report the incidents when the facility's investigation was unable to rule out abuse was discussed with Staff 1, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to the survey team exiting from facility.  

Based on observation, interview and record review, it was determined the facility failed to ensure reports of abuse and suspected abuse were reported to the local Seniors and Peoples with Disabilities (SPD) office immediately and incidents and injuries of unknown cause were investigated to rule out abuse and neglect or reported to the local SPD office for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose records were reviewed. Findings include but are not limited to:

1. Resident 3 was admitted to the facility in 08/2023 with diagnoses including dementia with mood disorder.

Review of the 12/18/23 through 03/16/24 progress notes, incidents reports and 03/08/24 service plan and Temporary Service Plans (TSP's) noted the following:

* 01/12/24 - "Resident was very agitated, being verbally aggressive toward staff and peers. The continuing hollering agitated [unsampled resident]. [Unsampled resident] walked up behind resident's neck and then squeezed."; and

* 02/06/24 - "Resident was sitting at the dining room table when [s/he] seen a peer walking towards [him/her], [s/he] began to yell and became verbally aggressive using vulgar language towards [him/her]. [Unsampled resident] walked by but when resident didn't stop, [unsampled resident] turned and grabbed resident by [his/her] arm then squeezed."

The facility lacked documented evidence the reports of abuse were immediately reported to the local SPD office and investigations into the abuse lacked documentation of an administrator's review.

In a 03/21/24 interview with Staff 1 (ED), she confirmed the reported abuse was not reported to the local SPD office and the investigations into the reports of abuse lacked documentation of an administrator's review.

The need to ensure reports of abuse were immediately reported to the local SPD office and investigations into reported abuse included an administrator's review

was discussed with Staff 1 and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged  the findings.

The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to survey exit.  

2. Resident 5 was admitted to the facility on 01/04/24 with diagnoses including Alzheimer's disease with agitation.

Review of the 01/04/24 through 03/18/24 progress notes, incident reports, 02/22/24 service plan and Temporary Service Plans (TSP's) indicated the following:

* 01/19/24 - "Resident was found in the room of a peer and they were both undressed in [his/her] bed";

* 01/20/24 - "Resident found in [unsampled resident] room nude."; and

* 02/29/24 - "[Resident 5] came into river house and walked over to [unsampled resident] and another...resident. [Unsampled resident] tried to sit next to the other two residents in river house when [Resident 5] began close fist hitting [unsampled resident] They were separated by care staff and [unsampled resident] taken back to [his/her] pod..."

The facility lacked documented evidence the reported abuse and suspected abuse was reported to the local SPD office immediately and investigation into the suspected abuse included an administrator's review.

In a 03/21/24 interview, Staff 1 (ED) confirmed the reported abuse and suspected abuse were not reported to the local SPD office and investigations into the suspected abuse did not included an administrator's review.

The need to ensure incidents of suspected abuse were immediately reported to the local SPD office and investigations into suspected included an administrator's review was discussed with Staff 1 and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings.

The facility was directed to self-report the incidents to the local SPD office. Confirmation of the report was received on 03/21/24 prior to survey exit.  

4.  Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia

The resident's current service plan, dated 12/22/23, progress notes, dated 12/23/23 through 03/07/24, Temporary Service Plans, incident reports and investigations were reviewed, and staff were interviewed. Multiple incidents were identified:

* 12/18/23: Unwitnessed, fall with lip injury;

* 12/28/23: Unwitnessed, fall with skin tear to left arm;

* 01/05/24: Unwitnessed, fall with injury to head and right knee;

* 01/10/24: Unwitnessed, fall with injury to right hand and fingers;

* 01/23/24: Unwitnessed, fall with re-opened scab to right knee;

* 01/25/24: Unwitnessed, fall with new skin tear to right knee;

* 01/30/24: Unwitnessed, fall without injury;

* 02/07/24: Unwitnessed, fall without injury; and

* 03/03/24: Unwitnessed, fall with rib pain and difficulty breathing.

There was no documented evidence the facility conducted an investigation to reasonably conclude the falls were not the result of abuse or neglect.

During an interview on 03/20/24 at 10:35 am, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed the above incidents had not been reported to the local unit.

The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the unwitnessed falls was received on 03/21/24.

The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 and Staff 7 on 03/21/24. They acknowledged the findings.

5. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Review of the 12/18/23 through 03/06/24 progress notes, incidents reports, outside provider notes and Temporary Service Plans (TSP's) indicated the following:

* On 02/08/24 progress notes indicated "resident is on alert for 2 abrasions unwitnessed injury/on the right side under shoulder blade". An outside provider note on 02/08/24 from the hospice MSW (Medical Social Worker) noted that "Per med aide, Pt [patient] fell today, but was more of a slide out of [his/her] wc [wheelchair]";

* On 02/09/24 an incident report identified Resident 6 had an unwitnessed fall in the bathroom and no injuries were identified; and

* On 02/09/24 an outside provider note from the hospice nurse identified resident's right ring finger was "red, swollen and tender to touch, patient cannot recall exactly how it occurred."

There was no documented evidence the unwitnessed falls and injuries of unknown cause were investigated to rule out abuse or neglect.

The surveyor requested the incidents be reported to the local SPD office. Verification the facility reported the unwitnessed falls and injuries of unknown cause was received on 03/21/24.

The need to promptly investigate all incidents to rule out abuse and/or neglect was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

ED completed abuse/neglect/reporting training on 3/20/2024.

All incidents were reported while survey team was on site.

All staff will complete abuse/neglect training. The BOM/designee will create a tracker list and monitor for completeness.

ED/AED/designee will investigate and self report to APS as required any report of potential abuse/neglect as required. This will be monitored by the RN 3 days/week x 2 months, 2 days/week x 1 month, and weekly x 2 months or until compliance is achieved. This will be monitored by review of incident reports, progress notes, and shift report logs.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were updated or changed as appropriate within the first 30-days after move-in for 1 of 1 sampled resident (#5) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease with agitation.

a. The resident's new move-in evaluation dated 12/27/23 was reviewed and the following elements were not addressed:

* Customary routines including eating and bathing;

* Mental Health issues including history of treatment;

* Cognition including decision making abilities;

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

* Fluid preferences;

* Unsuccessful prior placements; and

* Environmental factors that impact the resident's behavior including but not limited to noise.

b. The resident's initial evaluation was not updated or changed as appropriate within the first 30 days after move-in.

The need to ensure the move-in evaluation included all required elements and was updated or changed as appropriate within the first 30-days of move-in was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:55 pm. They acknowledged the findings.

An audit of all evaluation due dates will be completed by the ED/AED/Designee.

The ED/AED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families.

A weekly audit of evaluation/service plan dates will be done by the ED/AED/Designee x 4 weeks, every other week x  weeks and then monthly so that evaluations/service plans are completed prior to move in, within 30 days, quarterly and with changes of condition.

4. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the most recent service plan, dated 02/24/24, and temporary service plans, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas:

* Eating, including diet texture and fluid consistency, cutting up food and aspiration precautions/coughing;

* Instructions for oxygen use including when to use, liter flow, cleaning and replacing supplies;

* Fall precautions including use of fall mat and height of bed; and

* Skin integrity including ongoing redness in peri-area.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and was implemented was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia.

The current service plan, dated 02/22/24, and Temporary Service Plans from 12/08/23 to 02/02/24 were reviewed, and observations of Resident 2 and interviews with staff were completed during the survey.

The service plan was not reflective of the resident's current status, did not provide clear direction to staff, and was not implemented in the following areas:

* Weight loss status;

* Fall interventions;

* Level of assistance required with toileting, oral care, grooming and dressing; and

* Conflicting direction for meal assistance.

The need to ensure service plans were reflective of  the resident's current needs and preferences, provided clear direction regarding the delivery of services and were implemented was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

3. Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia, idiopathic sleep with oxygen desaturation (drops in blood oxygen levels) during sleep and type II diabetes with current use of insulin.

The current service plan, dated 02/22/24, and observations and interview of Resident 4 were completed during the survey. The service plan was not reflective of the resident's current status and did not provide clear direction to staff in the following areas:

* Oxygen treatment including setting and tubing care;

* Use of side rails; and

* Monitoring low and high blood sugar.

The need to ensure service plans were reflective of  the resident's current needs and preferences and provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

5. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia.

a. Observations of the resident, interviews with staff and review of the most recent service plan, dated 12/22/23, and temporary service plans, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas:

* Use of psychotropic medications;

* Frequency of location checks;

* Use of fall mat;

* Use of alternating pressure mattress;

* Frequency of routine incontinence care;

* Use of glasses;

* Assistance required with meals and transfers;

* Blood pressure checks;

* Use of bed rail; and

* Hospice provider.

b. The service plan was not readily available to staff upon survey entry. The surveyor requested Staff 6 (Health Service Director, RN) to ensure the service plan be readily available to staff on 03/20/24 at 11:30 am. The service plan was not observed to be available to staff until 03/21/24 at 1:45 pm.

The need to ensure resident service plans were readily available to staff, reflective of current care needs, provided clear direction to staff, and was implemented was discussed with Staff 1 (ED), Staff 6, and  Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, were implemented, reviewed and updated within 30-days of move-in, and was readily available to staff, for 5 of 6 sampled residents (#s 1, 2, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2024 with diagnoses including Alzheimer's disease with agitation.

a. Observations of the resident, interviews with staff, review of the 02/22/24 service plan, temporary service plans dated 01/04/24 through 02/10/24, and "Observation" notes dated 01/05/24 through 03/06/24 identified Resident 5's service plan was not reflective of his/her needs and preferences, lacked clear direction to staff, and/or was not implemented in the following areas:

* Relationship status with other memory care resident(s);

* Customary routines including eating and bathing;

* Sleep patterns including interventions for insomnia;

* Skin integrity and care;

* Oral and dental assistance;

* Mobility with assistive devices for fall risks including the use of glasses;

* Toileting and incontinent assistance and care;

* Interests, hobbies, social and leisure activities;

* Speech and communication;

* Cognition including memory, orientation, confusion, and decision making abilities;

* Use of PRN psychotropic medication;

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

* Nutrition including texture of diet and fluid preferences; and

* Emergency evacuation.

b. The service plan was not reviewed and updated to reflect the resident's needs and preferences within 30-days of move-in to ensure changes accurately reflected the resident's needs and preferences.

c. The service plan was not readily available to staff upon survey entry. On 03/19/24, this surveyor asked Staff 2 (Assistant ED) if the service plan available to staff was the most recent service plan. Staff 2 stated it was not the most recent service plan and was aware it needed to be printed and available to staff. On 03/21/24 at 10:25 am, the service plan was not observed to be available to staff.

The need to ensure service plans were reflective of the resident's needs and preferences, provided clear direction regarding the delivery of services, services were implemented, were reviewed and updated within 30-days of move-in, and was readily available to staff was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:55 pm. They acknowledged the findings.

An audit of all evaluation due dates will be completed by the ED/AED/Designee.

The ED/AED/Designee will audit all evaluations/service plans to ensure that all required items are captured with input from care staff, programming staff, resident and families and reflective of current care needs and updated as appropriate.

A weekly audit of evaluation/service plan dates will be done by the ED/AED/Designee x 4 weeks, every other week x  weeks and then monthly so that service plans are completed prior to move in, within 30 days, quarterly and with changes of condition and they are readily available to staff.

2. Resident 2 was admitted to the facility 01/2022 with diagnoses including dementia.

a. Observations of the resident on 03/18/24 and 03/21/24 revealed the resident required hands-on assistance to eat meals and drink liquids.

Resident 2's 02/22/24 service plan, Temporary Service Plans (TSPs), 12/02/23 through 03/17/24 progress notes, 08/30/23 physician orders and 09/2024 through 03/2024 weight records were reviewed and showed the following:

* On 08/30/23, physician order indicated to measure and record the resident's weight monthly;

* 12/03/23 through 12/08/23, the resident was on alert charting for "pocketing food/chocking [sic] risk"; and

* A 12/08/23 TSP informed staff that the resident's "diet has changed to puree, staff to provide 1:1 feeding support for all meals and snacks."

Resident 2's weight record showed the resident experienced a weight loss of 9.4 pounds between 09/2023 (117.4 lbs) and 12/2023 (108.0 lbs) or 8 % of his/her total body weight. The resident experienced another significant weight loss of 6.11 % in one month from 12/2023 to 01/2024 (101.4 lbs). There were no weights recorded in 02/2024 to review. During the survey, the resident's weight was measured on 03/21/24, and the weight was 95.4 pounds.

During the survey on 03/20/24 between 9:00 am and 1:00 pm, the following was observed:

* From 9:00 am to 10:40 am, the resident was in the recliner in TV area;

* From 10:40 am to 11:45 am, the resident was walking around the facility without breaks;

* None of staff offered beverages or snacks to the resident during the observation between breakfast and lunch; and

* At 12:49 pm, the resident was in the dining room for lunch. Staff provided 1 on 1 meal assistant. The resident consumed most of food.

There was no documented evidence in the resident's records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment.

During an interview, 03/18/24, Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed they had not been monitoring the resident's weights. The facility failed to have a monitoring system in place to review the resident's weights. The weight loss represented a significant to severe amount of weight lost.

This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated.

b. The following short-term changes lacked documented evidence the resident's conditions were monitored until resolution:

* 12/13/23: Fall with injury on head and face;

* 12/17/23: Alert for having diarrhea; and

* 01/06/24: Alert for medication changes.

On 03/21/24, the need to monitor the resident's conditions through resolution, with at least weekly documentation, was discussed with Staff 1 (ED), Staff 6 and Staff 7. They acknowledged the findings.

4. Resident 3 was admitted to the facility in 08/2023 with diagnoses including dementia with mood disorder.

a. Review of the 12/06/23 through 03/13/24 progress notes, 03/08/23 service plan, and Temporary Service Plans (TSP's) revealed Resident 3 experienced the following short-term changes of condition:

* 12/20/23 - Medication refusals;

* 12/28/23 - Positive for Covid-19;

* 12/29/23 - Medication refusals;

* 01/03/24 - Aggressive behaviors; and

* 01/23/24 - Medication refusals.

The facility lacked documented evidence actions or interventions were developed and communicated to staff on each shift and changes of condition were monitored, with progress noted at least weekly through resolution, for each of Resident 3's short-term changes of condition.

b. Review of the resident's 09/03/23 through 02/02/24 weight records revealed Resident 3 experienced the following weight changes:

* 09/03/23 - 166.9 ponds;

* 10/26/23 - 173.6 pounds;

* 12/03/23 - 183.2 pounds; and

* 01/05/24 - 172.4 pounds.

According to the records, Resident 3 gained 16.3 pounds in a three month period between 09/2023 and 12/2023 for a total of 9.76% increase in total body weight.

This constituted a significant change of condition.

The facility lacked documented evidence the resident was evaluated for the significant change of condition and referred to the facility RN for assessment.

The need to ensure the facility had a system to refer residents who experienced significant changes of condition to the RN for assessment, determine and document what actions or interventions were needed for a resident's short-term changes of condition, ensure actions or interventions were communicated to staff on each shift, and ensure progress was documented at least weekly until the conditions resolved was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings.

Based on observation, interview and record review it was determined the facility to ensure short term changes were evaluated, actions or interventions communicated to staff on each shift, resident specific interventions determined and documented, and the condition monitored with weekly progress noted until resolution for 4 of 4 sampled residents (#1, 2, 3, and 6) who experienced short term changes in the areas of skin and medication changes; and failed to evaluate and monitor service plan interventions for 1 of 1 sampled residents (#1) who had repeated falls, and 2 of 2 sampled residents (#s 2 and 6 ) who had significant weight loss. Resident 1 continued to have falls with injury, and Residents 2 and 6 continued to have weight loss. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia.

Interviews with staff, observations of the resident, and review of the resident's 12/22/23 service plan, 12/18/23 through 03/03/24 Temporary Service Plans (TSPs), progress notes, and incident investigations were reviewed.

Fall prevention interventions listed on the 12/22/23 service plan included hands on assistance from two people for all transfers, use of wheelchair and ambulation for short distances with supervision, and for staff to assess him/her when restless and getting out of bed without assistance for unmet needs such as discomfort, need to toilet, or hunger.

a. Resident 1 experienced the following unwitnessed 10 falls between 12/18/23 and 03/03/24:

* 12/18/23: Fall with lip injury;

* 12/28/23: Fall with skin tear to the left arm;

* 01/03/24: Non-injury fall, found crawling on floor;

* 01/05/24: Fall with skin tears to scalp and right knee;

* 01/10/24: Fall with injury to right hand and fingers;

* 01/23/24: Fall with re-opened scab to right knee;

* 01/25/24: Fall with new skin tear to right outer knee;

* 01/30/24: Non-injury fall, found on fall mat next to bed;

* 02/07/24: Non-injury fall; and

* 03/03/24: Fall with rib pain and difficulty breathing.

Resident 1 experienced the following witnessed four falls between 12/18/23 and 02/16/24:

* 12/18/23: Fall with redness to the left thigh and a cut "the size of a bean" on the left toe;

* 12/21/23: Non-injury fall in room;

* 02/08/24: Fall out of wheelchair, hit head with no new injuries; and

* 02/16/24: Non-injury fall in activities room.

During an interview on 03/18/24 at 2:35 pm, Staff 13 (CG) stated staff always used a fall mat while Resident 1 was sleeping, and this recommendation came from hospice staff. Staff 13 stated that there was no specific time frame, but staff "had to keep an eye" on Resident 1 due to frequent falls, but it was difficult when assisting other residents. Staff 13 stated Resident 1 generally required assistance of one person for transfers, ambulation and wheelchair mobility.

The resident was observed sleeping in his/her bed multiple times on 03/19/24 and 03/20/24 with a gray fall mat placed beside it.

During interviews on 03/20/24, Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) confirmed there was no additional documentation for review.

There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall and sustained multiple injuries.

This represented a situation that placed the resident at risk for further falls. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the falls was submitted and the situation was abated.

b. TSPs were created, but progress was not documented at least weekly through resolution, for the following interventions:

* 12/18/23: "Check to see if [s/he] is constipated."; and

* 12/28/23: "Monitor resident every 2 hours" and "Report to MT for any behavior changes."

The need to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 6 and Staff 7 03/21/24.  No further documentation was provided.

3. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

The resident's 02/24/24 service plan, 02/26/24 physician orders, 12/18/23 through 03/06/24 progress notes, 02/01/24 through 03/18/24 MARs, incident reports and investigations and outside provider notes were reviewed. The following was identified:

a. The service plan indicated Resident 6 used utensils for eating and required food to be cut up "to nickel size of [or] smaller prior to serving it to [him/her.]" Physician orders indicated an order for mechanical soft diet with nectar thickened liquids.

Observations of the resident during lunch on 03/18/24 and 03/19/24 revealed the resident required his/her food to be cut up, assistance with meal set up and supervision for meal assistance while eating.

Resident 6's weight record was reviewed during the survey and revealed the following:

* 12/05/23 - 181.6 pounds;

* 01/05/24 - 169.7 pounds;

* 03/06/24 - 163.3 pounds; and

* 03/20/24 - 161.7 pounds (weight obtained during survey).

From 12/2023 to 01/2024, Resident 6 had weight loss of 11.9 pounds or 6.6% of his/her body weight in one month, which resulted in a severe loss and represented a significant change of condition.

Weights documented after 01/2024 revealed the resident experienced another significant weight loss of 11% in three months from 12/2023 to 03/2024. There were no weights recorded in 02/2024 to review.

There was no documented evidence in the resident's records the weight loss had been evaluated, actions or interventions had been determined to address the weight loss and communicated to staff, the facility was monitoring for subsequent weight loss, or had referred to the RN for a significant change of condition assessment. Resident 6 continued to experience severe weight loss.

During the survey the following was observed:

* On 3/18/24 Resident 6 was served lasagna, not cut up, regular sized pieces of green salad with dressing, two rolls, pre-thickened apple juice and milk. The resident was observed eating lasagna with his/her fingers. S/he consumed 100% of the meal.

* On 3/19/24 Resident 6 was served noodles, cut up pieces of beef, a roll and regular sized pieces of salad with cut up tomatoes and dressing, and pre-thickened water, apple juice and milk to drink. S/he did not initiate eating until staff prompted him thirteen minutes after food was delivered and placed a spoon in his/her hand. The resident set the spoon down, then proceeded to eat noodles and beef with his/her fingers, grabbed handfuls of salad and licked his/her fingers and hand afterwards. S/he ate 98% of his/her meal including drinks.

* Resident 6 was not offered dessert of chocolate cream pie on 3/19/24.

* The resident coughed throughout lunch on 3/18/24 and 3/19/24.

In an interview on 03/20/24 with Staff 6 (Health Services Director, RN) she acknowledged Resident 6 had not been evaluated and referred to the facility nurse for  the severe weight loss in January 2024 and again in March 2024.

The failure to evaluate the significant change of condition, and update the service plan as needed resulted in ongoing severe weight loss.    

This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated.

b. The following short-term changes lacked documented evidence that actions or interventions were determined, documented, communicated to all staff on all shifts and/or monitored until resolution:

* 01/09/24 - "persistent groin redness";

* 02/05/24 - Multiple missed medications;

* 02/08/24 - Two abrasions on back;

* 02/09/24 - Non-injury fall;

* 02/09/24 - Right ring finger "red, swollen and tender to the touch";

* 03/01/24 - Redness on right big toe;  

* 03/15/24 - Redness on coccyx; and

* Multiple medications that were missed, refused, and/or not available.

On 03/20/24 and 03/21/24, the need to evaluate changes of condition, refer changes to the facility nurse when needed, determine actions or interventions and communicate them to staff, and monitor through resolution, with at least weekly documentation, was discussed with Staff 1 (ED), Staff 6, and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Med Techs, Caregivers and culinary staff educated by the ED/AED/RN about the weight process, nutrition and hydration, and snacks

a.All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED/AED or designee and appropriate interventions placed on a TSP and on the service plan.

i.Interventions in place at this time for this resident are:

1.Low bed

2.Fall mat on the floor beside the bed

ii.A call was placed on 3/21/2024 to Bristol hospice to request:

1.Non-skin cushion for wheelchair

2.Geri hip protectors

iii.The service plan will be updated on 3/21/2024 to reflect interventions in place and new interventions and a TSP will be put into place and a change of condition will be completed by the RN by EOD 3/21/2024.

d.The ED will monitor the EHR at least 4 days/week for incidents and progress notes.  

e.The ED/AED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI.

f.The ED/AED or designee will put into place a TSP for each incident. The RN will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions.

g.The ED/AED or designee will self report to APS as required any report of potential abuse/neglect.  This will be monitored by the RN 3 days per week x 2 months, 2 days per week x 1 month, and weekly x 2 months or until compliance is achieved 100% of the time by review of incident reports, progress notes and shift report logs.

h.The ED/AED or designee is responsible to notify the RN of any resident with 2 or more falls.

2.Weight Loss-Significant change of condition

a.The med techs, caregivers, and culinary staff will be educated by the ED, VP of Clinical Operations, and RN about the weight process, nutrition and hydration, and snacks by 3/25/2024.

b.The ED/AED is responsible to ensure that the weights are done by the 5th of each month and logged in the binder/EHR system.

c.A review of monthly weights will be done by an RN by the 10th of each month. The RN will complete any change in condition assessment, contact the physician and family, and ensure interventions are on the care plan.  

d.The ED/AED is responsible to ensure that weekly weights are done as ordered.

e.A review of the weekly weights will be done by an RN weekly.

f.Hydration stations were put into place at the med tech station, and each neighborhood on 3/21/2024. The culinary staff will ensure that they are refreshed two times per day (morning and afternoon).

i.Interventions in place for (female) resident with weight loss include:

1.Referral to hospice (by NP)

2.Fortified foods with meals

3.Offer snack/fluid at snack times throughout the day (10,3,7) in addition to meals.

4.1:1 feeding assist at meal times

ii.Interventions for (male) include:

1.Hospice is on board and has been and will obtain their notes from November on, and request interventions from them.  

2.Encouragement or hand over hand feeding at meal times if needed

3.Staff will offer snack/fluids at snack times during the day (10, 3, 7) in addition to meal times.

The RN is enrolled in the "Role of the Nurse" Course in April 2024.  

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN performed an assessment which documented findings, resident status, and interventions made as a result for 2 of 2 sampled residents (#s 2 and 6) who experienced a significant change of condition in weight status. Resident 2 and 6 continued to have weight loss. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2022 with diagnoses including dementia.

Observations of the resident on 03/18/24 and 03/21/24 revealed the resident required hands-on assistance to eat meals and drink liquids.

Resident 2's weight record was reviewed during the survey and revealed the following:

* 09/2023 - 117.4 pounds;

* 12/2023 - 108.0 pounds;

* 01/2024 - 101.4 pounds; and

* 03/21/24 - 95.4 pounds.

From 09/2023 to 12/2023, Resident 2 had weight loss of 9.4 pounds or 8.00 % of his/her body weight, which represented a significant change of condition.

Weights documented after 12/2023 revealed the resident experienced another significant weight loss of 6.11 % in three months from 12/2023 to 03/2024. There were no weights recorded in 02/2024 to review.

There was no documented evidence the RN completed an assessment of the resident's condition which included findings, resident status and interventions made as a result of the assessment to address the weight loss.

During the survey on 03/20/24 the following was observed:

* From 10:40 am to 11:45 am, the resident was walking around the facility without breaks;

* None of staff offered beverages or snacks to the resident during the observation; and

* At 12:49 pm, the resident was in the dining room for lunch. Staff provided 1 on 1 meal assistance. The resident consumed the most of the meal.

The failure to complete a RN assessment at the time of the significant weight loss and failure to initiate interventions resulted in additional weight loss.

This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated.

On 03/21/24, the above findings, lack of an RN assessment and further weight loss were shared with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

Refer to C270, example 2a.

2. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Observations of the resident on 03/18/24 and 03/19/24 revealed the resident required his/her food to be cut up, assistance with meal set up, and supervision for meal assistance while eating.

Resident 2's weight record was reviewed during the survey and revealed the following:

* 12/05/2023 - 181.6 pounds;

* 01/05/2024 - 169.7 pounds; and

* 03/06/2024 - 163.3 pounds.

From 12/2023 to 01/2024, Resident 6 had weight loss of 11.9 pounds or 6.6% % of his/her body weight, which represented a significant change of condition.

Weights documented after 01/2024 revealed the resident experienced another significant weight loss of 10% in three months from 12/05/23 to 03/06/24. There were no weights recorded in 02/2024 to review.

On 3/20/24 at 11:20 am an interview with Staff 6 (Health Services Director, RN) acknowledged there was no RN assessment done for the significant weight loss on 01/05/24 and 03/06/24.

During the survey the following was observed:

* On 3/18/24 Resident 6 was served lasagna, not cut up, regular sized pieces of green salad with dressing, two rolls, pre-thickened apple juice and milk. The resident was observed eating lasagna with his/her fingers. S/he consumed 100% of the meal.

* On 3/19/24 Resident 6 was served noodles, cut up pieces of beef, a roll and regular sized pieces of salad with cut up tomatoes and dressing, and pre-thickened water, apple juice and milk to drink. S/he did not initiate eating until staff prompted him thirteen minutes after food was delivered and placed a spoon in his/her hand. The resident set the spoon down, then proceeded to eat noodles and beef with his/her fingers, grabbed handfuls of salad and licked his/her fingers and hand afterwards. S/he ate 98% of his/her meal including drinks.

* Resident 6 was not offered dessert of chocolate cream pie on 3/19/24.

* The resident coughed throughout lunch on 3/18/24 and 3/19/24.

From 12/05/23 through 03/06/24, the resident lost a total of 18.3 pounds, or 10% of his/her total body weight. An RN assessment was not completed that included findings, resident status, and interventions made as a result of the assessment. There was no documented evidence new actions or interventions were identified. Resident 6 continued to have significant weight loss.

This represented a situation that placed the resident at risk for further weight loss. The survey team requested an immediate plan to correct the rule violation. On 03/21/24 at 2:30 pm, a plan to address the weight loss was submitted and the situation was abated.

The need to ensure significant changes of condition were assessed by an RN and included findings, resident status, and interventions made as a result of the assessment, as well as ensuring they were completed in a timely manner, was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Refer to C270, example 6a.

Med Techs, Caregivers and culinary staff educated by the ED/AED/RN about the weight process, nutrition and hydration, and snacks

a.All falls whether witnessed or unwitnessed will be investigated within 24 hours by the ED/AED or designee and appropriate interventions placed on a TSP and on the service plan.

i.Interventions in place at this time for this resident are:

1.Low bed

2.Fall mat on the floor beside the bed

ii.A call was placed on 3/21/2024 to Bristol hospice to request:

1.Non-skin cushion for wheelchair

2.Geri hip protectors

iii.The service plan will be updated on 3/21/2024 to reflect interventions in place and new interventions and a TSP will be put into place and a change of condition will be completed by the RN by EOD 3/21/2024.

d.The ED will monitor the EHR at least 4 days/week for incidents and progress notes.  

e.The ED/AED or designee is responsible to complete an investigation on every incident within 24-48 hours, and document on the QAPI.

f.The ED/AED or designee will put into place a TSP for each incident. The RN will be notified and will review the TSP, add the interventions to the care plan, and monitor effectiveness of the interventions.

g.The ED/AED or designee will self report to APS as required any report of potential abuse/neglect.  This will be monitored by the RN 3 days per week x 2 months, 2 days per week x 1 month, and weekly x 2 months or until compliance is achieved 100% of the time by review of incident reports, progress notes and shift report logs.

h.The ED/AED or designee is responsible to notify the RN of any resident with 2 or more falls.

2.Weight Loss-Significant change of condition

a.The med techs, caregivers, and culinary staff will be educated by the ED, VP of Clinical Operations, and RN about the weight process, nutrition and hydration, and snacks by 3/25/2024.

b.The ED/AED is responsible to ensure that the weights are done by the 5th of each month and logged in the binder/EHR system.

c.A review of monthly weights will be done by an RN by the 10th of each month. The RN will complete any change in condition assessment, contact the physician and family, and ensure interventions are on the care plan.  

d.The ED/AED is responsible to ensure that weekly weights are done as ordered.

e.A review of the weekly weights will be done by an RN weekly.

f.Hydration stations were put into place at the med tech station, and each neighborhood on 3/21/2024. The culinary staff will ensure that they are refreshed two times per day (morning and afternoon).

i.Interventions in place for (female) resident with weight loss include:

1.Referral to hospice (by NP)

2.Fortified foods with meals

3.Offer snack/fluid at snack times throughout the day (10,3,7) in addition to meals.

4.1:1 feeding assist at meal times

ii.Interventions for (male) include:

1.Hospice is on board and has been and will obtain their notes from November on, and request interventions from them.  

2.Encouragement or hand over hand feeding at meal times if needed

3.Staff will offer snack/fluids at snack times during the day (10, 3, 7) in addition to meal times.

The RN is enrolled in the "Role of the Nurse" Course in April 2024.  

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 03/18/24, the resident was identified to receive insulin injections from non-licensed staff.

Resident 4's MARs, reviewed from 03/01/24 through 03/18/24, revealed insulin had been given by Staff 9 (MA) Staff 25 (MA), Staff 26 (MA), and Staff 27 (MA) on multiple occasions.

a. Review of Resident 4's delegation documentation on 03/20/24 revealed there was no documented evidence Staff 25 and Staff 27 were delegated for the insulin administration to Resident 4.

On 03/20/24 at 12:25 pm, Staff 6 (Health Services Director, RN) confirmed there was no documented delegation completed for Staff 25 and Staff 27. Staff 6 was informed that Staff 25 and Staff 27 should not administer insulin to Resident 4 until staff were delegated.

b. The most recent periodic inspection, supervision and re-evaluation of the delegation of insulin for Staff 9 and Staff 26, completed 12/20/23 and 12/19/23, was reviewed. The initial re-evaluation was not completed within 60 days of the initial delegation for Staff 9 and Staff 26.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24 at 2:25 pm. They acknowledged the findings.

RN is scheduled for Role of the Nurse course 4/23-4/25

The AED will ensure that the med techs scheduled are delegated and there is a plan in place for delegation

All med techs will be educated regarding signing out of ALIS; closing computer screen when leaving med cart; locking med cart at all times when back is turned.

Agency training checklist will be implemented and signed off when an agency staff comes in for a shift

RN will upload delegations into ALIS under staff profile (and also keep in binder as required)

RN Will set expiration dates on delegation to track timelines

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia.

Resident 1 was identified during the acuity interview on 03/18/24 as receiving hospice services.

Review of progress notes and "Outside Provider Communication Forms" from 01/22/24 through 03/13/24 included the following information made by the provider:

* 01/22/24: "P.T. eval. today [with] fall prevention recommendations, please see back for recs."; and

* 01/30/24: "Staff to continue with visual checks, fall mat out, call hospice with falls."

The facility was unable to provide the back page of the physical therapist's recommendations on 01/22/24. The facility requested the note from the hospice provider on 03/21/24, and it included the following information:

* "Rec [recommended] pursue soft palm protector that is secured around hand and palm to decrease risk for sores and nails [fingernails]causing injury to palm.";

* "PT rec [recommended] room arrangement including moving bed to wall where TV, this will allow direct line of site for cg, head of bed towards window but placing table between window and bed as PT also rec [recommended] moving recliner chair next to HOB [head of bed] and may need a bit of room at head to assure space."; and

* "Rec [recommended] bed rails in place with padding, RN to order for pt [patient] safety, and fall mat in place, removing blue (very slick) pad and keeping grey fall mat next to bed, then placing w/c [wheelchair] near foot of bed with brakes locked in place if pt [patient] does attempt to get out of bed, keep doors open but this will allow frequent visual site of pt [patient]."

The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care.

The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by on-site outside providers were communicated to staff and service plans adjusted if necessary, and protocols were in place for 2 of 2 sampled residents (#s 1 and 6) who received outside services. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 6 was identified during the acuity interview on 03/18/24 as receiving hospice services.

Review of progress notes and "Outside Provider Communication Forms" from 01/29/24 through 03/18/24 included the following information made by the provider:

* 02/09/24: "R [right] hand ring finger is red, swollen and tender to touch,";

* 02/16/24: "R [right] ring finger still tender to touch";

* 03/01/24: "R [right] big toe presenting with redness"; and

* 03/15/24: "Coccyx has redness present..."

The facility lacked documented evidence the information was communicated to direct care staff or the service plan was adjusted to ensure continuity of care.

The need to ensure staff were informed of on-site outside provider information and interventions and the service plan adjusted if necessary was reviewed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Outside provider notes will be reviewed weekly to ensure any orders are properly written and carried out and communicated to staff by the ED/AED/RN/Designee.   

Recommendations from an outside provider are not considered an order, the ED/AED/RN/Designee will follow up on recommendations weekly to obtain proper orders for these items and implement TSPs for the staff communication.  

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 2 of 2 sampled residents (#s 2 and 6) who received incontinence care and meal assistance from staff and multiple unsampled residents. Findings include, but are not limited to:

1a. Resident 2 moved into the facility in 01/2022 with diagnoses including dementia.

Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs and was on a pureed-texture diet requiring meal assist.

During the survey, from 03/18/24 through 03/20/24, multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal service to Resident 2. Care staff were not wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service.

b. Lunch service was observed on 03/18/24 and 03/20/24.

Staff were observed setting tables with napkins and silverware, serving meals and beverages, touching residents, removing dirty dishes and opening the kitchenette door without changing their gloves or performing hand washing.

The above observation was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. The staff acknowledged that appropriate infection control practices were not followed.

4. Observations were made during the survey to determine adherence to universal precautions for infection control.

* On 03/18/24, at 12:03 PM, the surveyor observed Staff 20 (CG) providing lunch meal service to the residents of Mountain house. At 12:48 pm, Staff 20 was observed handling two partially eaten plates of food bare handed. The thumbs of both hands were visible on the surface of the plates near the partially eaten food. Staff 20 set the plates on the counter in the kitchenette and proceeded to touch the kitchenette door handle, the door handle and door frame of unit 304 and the kitchenette door handle again with her right hand without performing proper hand hygiene.

On 03/18/24 at 12:53 pm, the surveyor spoke to Staff 20 regarding the need to maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. She acknowledged the findings.

On 03/21/24, the need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) They acknowledged the findings.

2. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

During interviews and observations from 03/18/24 through 03/21/24, Resident 6 was noted to require one to two person assist for toileting and one person assist with dressing.

During an ADL observation on 03/19/24 at 1:00 pm the following was noted:

* A caregiver escorted the resident into his/her bathroom in a wheelchair and donned gloves. The resident transferred to the toilet with assistance from the caregiver, she doffed his/her pants, removed the soiled brief and put it on the floor, then assisted the resident in sitting down onto the toilet. With the same soiled gloves, the caregiver retrieved a clean brief outside the bathroom touching the resident's cabinet door and bathroom door handles. While she assisted in donning the clean brief, she also touched Resident 6's pants, shoes, arms, shirt and wheelchair push handles and brakes.

* The caregiver then bagged up the dirty briefs, removed the gloves, threw away the trash and performed hand hygiene.

The observation was discussed with Staff 6 (Health Services Director, RN) on 3/21/24 and she acknowledged appropriate infection control practices needed to be followed in regards to incontinence care.

3. On 03/18/24, observations during lunch service identified the following:

At 12:35 pm, a caregiver provided meal assistance to two unsampled residents and was not wearing a protective garment. The caregiver stood between the two residents while she provided meal assistance to both residents with her left hand. She was observed holding each of the resident's forks and cups as she alternated assisting each resident simultaneously with no handwashing in between.

12:42 pm, the caregiver briefly stopped providing meal assistance to these two residents while she left the table to bring desserts to another group of residents. Afterwards, she returned to the table and resumed meal assistance for the two residents.  No handwashing was observed prior to serving desserts or resuming meal assistance.  

The need to ensure staff consistently used universal precautions when providing incontinence care and meal service was discussed Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

all staff will complete infection control training to include handwashing, incontinence cares, dining assistance. The BOM/designee will have a list of staff names, track completion certificates and follow up.

Observe 2 random care staff per week providing incontinence care x 8 weeks, 1 staff per week x 4 weeks, and then 1 x per month until compliance is achieved.

ED/CSD will educate all staff that culinary services staff will plate food at each meal. The caregivers will be responsible for delivering the plates to the residents and assisting with meals.

ED will develop MOD in dining room and educate all managers on the expectations of meal service and expectation of following the schedule

Program director will implement the handwashing out of meaningful moments and ensure that the staff are educated on the process

MOD in the dining room will ensure this is happening at meals

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Residents were put at risk related to failure 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, to have an effective system for tracking controlled substances, to follow or have physician orders, a system in place to notify the physician/practitioner if a resident refused consent, inaccurate medication records, to ensure proper use of PRN psychoactive medications, and a system to complete demonstrated competency staff training in medication administration. Findings include, but are not limited to:

This constituted a finding needing an immediate plan of correction for the health and safety of residents.

During the re-licensure survey, conducted 03/18/24 through 03/21/24, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas:

* C 282: RN Delegation and Teaching;

* C 302: Systems: Tracking Control Substances;

* C 303: Systems: Medication and Treatment Orders;

* C 305: Systems: Resident Right to Refuse;

* C 310: Systems: Medication Administration; and

* Z 155: Staff Training Requirements.

On 03/21/24 at 10:05 am the survey team requested an immediate plan of correction to address the issues identified. At 2:30 pm, a plan was received and accepted by the survey team and the situation was abated.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed on 03/21/24 with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

a.Upon hire, medication techs will receive an orientation checklist. The ED/BOM will track the return of the orientation checklist within 3 working days.   

b.The BOM/designee will audit 10% of employee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance.  

c.When the medication tech has completed the orientation checklist, the AED/lead med tech or designee will do a return demonstration medication pass audit with the medication tech.

d.The ED/AED/RN will complete a return demonstration med pass audit with each current medication tech by 3/25/2024.

e.The RN, AED, or designee will complete a return demonstration med pass audit with each med tech quarterly.

f.The medication techs will be inserviced by the ED, AED, RN by 3/25/2024 to include:

i.Notifying the physician of medication refusals.

ii.Documentation of non-pharmacological interventions tried prior to giving a PRN.

iii.Calling the RN on call when they feel a PRN is needed prior to giving.

g.The ED/AED will pull the medication exception report at least 3 times per week to review refusals and ensure the communication was sent to the physician.  

h.The RN/designee will complete a full audit of physician orders by 3/22/2024 to ensure that:

i.Non-pharmacological interventions are associated with any PRN psychotropic medication, and

ii.The order in which to use any PRNs is clearly documented on the MAR.

i.The RN/Designee will then complete this audit monthly x 3 months, and then monthly.

j.A medication cart audit will be done weekly by the AED/ED or designee to identify medications that are low in supply. This will be done weekly on Wednesdays, and the AED/ED/designee will order any medications that are 7-14 days from running out and are not on cycle fill.

Med Techs will have a return demonstration med pass audit completed after the 3 working day orientation checklist is completed. ED/AED/designee

Medication Techs will have a quarterly med pass audit performedED/AED/designee. Immediately done by 3/25/2024 for all current med techs. Audits will be uploaded into ALIS and an expiration date set for quarterly.

C302-Controlled Substance

Inconsistent Narcotic CountED/AED/RNa Weekly audit of the narcotic books and count will be completed.

Med techs will be educated on the proper narcotic count process

C303 Physician Orders

Physician Orders not carried out as prescribedMicaela/CynthiaMed cart audit was completed

Micaela/CynthiaWeekly medication cart audit will be completed on Wednesday and the AED/ED/Designee will order any medications that are 7-14 days from running out and not on cycle fill.

C305 Residents Right to Refuse Medications

No physician notification of refusalED/AED/RNMed techs inserviced on 3/25/2024 by AED of the notification to physicians of medication refusals.

The ED/Designee will pull the medication exception report at least 3 x's/week and follow up on any refusal of medications that Physician notification occurred. If it did not occur, the Med tech will be re-educated and the ED/Designee will notify the physician

C310-Accuracy of MAR

Reason for useCynthia/Micaelaa complete audit of medication orders will be completed initially, and then monthly to ensure the correct diagnosis and reason for use is outlined on the MAR

Clear ParametersCynthia/ Micaelaa complete audit of medication orders  will be completed initially and then monthly. Clear parameters will be outlined on the MAR for any medication requiring.

Holes in MARCynthia/ MicaelaA weekly audit of medication exceptions will occur and med techs will be re-inserviced with subsequent corrective action

C330-Psychotropic Medication

non-pharmacological Interventions on the order for PRN psychotropic use.RNComplete audit of physician orders for non-pharmacological interventions listed

Clear direction on which medication to attempt first, second, third, etc. RNIf a resident has more than 1 medication for the same reason of use, the directions in which to ive first will be clearly outlined on the MAR

Documentation required of non-pharmacological interventions attemptedRNMed Techs inserviced about documentation requirements and will call RN prior to administration of PRN medication.

Rn/DesigneeRn will audit progress notes at least 3x's/weekly for documentation related to nonpharmacological interventions.

2. Resident 7 was moved into the facility in 06/2023 with diagnoses including dementia.

A review of Resident 7's 03/15/24 through 03/21/24 MARs showed s/he received morphine 10 mg every four hours scheduled and every hour as needed for pain and/or shortness of breath.

The MARs and the Controlled Substance Disposition Record revealed the following discrepancies:

* The Controlled Substance Disposition log showed the morphine was administered on five occasions on 03/16/24 and seven occasions on 03/20/24, however, the MAR showed only four occasions on 03/16/24 and six occasions on 03/20/24 that the medication was administered to Resident 7.

Inconsistencies between the MAR and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have an effective system for tracking controlled substances for 2 of 2 sampled residents (#s 6 and 7) who were administered PRN narcotic medication. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

The resident had a physician's order for morphine 0.25 ml (5mg) sublingually, every 15 minutes as needed for moderate pain and/or shortness of breath.

A review of Resident 6's 05/01/23 through 03/18/24 MARs and the Controlled Substance Disposition Record revealed the following discrepancies:

* The Controlled Substance Disposition log showed the morphine was administered on seven occasions between 05/18/23 through 01/14/24, however, the MAR showed only four occasions the medication was administered to Resident 6.

* On 03/21/24 at 1:05 pm, a comparison of the morphine bottle to the disposition log showed the amount of medication left was not reflected accurately on the log. Staff 6 (Health Service Director, RN) was present during this observation and confirmed that the bottled showed approximately 22.00 ml remaining and the disposition log indicated 26.00 ml remaining.

Inconsistencies between the medication bottle, MARs and Controlled Substance Disposition logs and the need to ensure the facility had an effective system for tracking controlled substances was discussed with Staff 1 (ED), Staff 6, and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

A Weekly audit of the narcotic books and count will be completed by the ED/AED/Designee.

Med techs will be educated on the proper narcotic count process by the AED/Nurse/Designee

Hospice providers will be notified that when ordering morphine, they will need to order pre-filled syringes of medication by the RN.

Based on observation, interview, and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 5 sampled residents (#s 4 and 6) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia and type II diabetes with long-term use of insulin.

The resident's 03/01/24 through 03/18/24 MARs and 02/15/24 physician's orders were reviewed and identified the following:

a. A physician's order indicated to administer Humalog 10 units with breakfast and dinner and 8 units with lunch. Hold if "CBG before meal is less than 120 mg/dl."                 

The MAR showed the insulin was administered when the CBG was 104 mg/dl on 03/02/24 at 8:00 am and the insulin was not administered when CBG was 325 mg/dl on 03/12/24 at 5:00 pm.

b. A physician's order indicated to administer glucose 40 % oral gel as needed for low blood sugar and the MAR directed staff to administer the gel when CBG was less than 70.

The MAR showed the resident's CBG was 48 mg/dl on 03/04/24 at 8:00 am and CBG was 68 mg/dl on 03/05/24 at 8:00 am. There was no documented evidence on the MAR that staff administered the glucose gel when the resident's CBG was less than 70.

On 03/21/24, the physician orders and the MARs were reviewed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

2.  Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 6's 02/01/24 through 03/18/24 MARs, corresponding progress notes, and physician's orders, dated 02/26/24 were reviewed. They showed the following:

a. Records revealed the following medications were not given as prescribed on the following dates, with documentation stating the "medication not available":

* Minerin cream (for dry itchy skin) on 02/28/24;

* Magnesium oxide (supplement) on 02/24/24, 02/28/24, 3/11/24 through 03/15/24;

* Secura protective cream (for redness/rash to groin) on 02/28/24;

* Sertraline (for depression) on 02/08/24, 02/24/24 through 03/02/24; and

* Trazodone (for depression/sleep) on 03/17/24.

b. Resident 6's physician orders indicated a mechanical soft diet with nectar thickened liquids.

* On 03/18/24 observations during lunch indicated Resident 6 was served pre-thickened nectar thick milk and apple juice. Staff were interviewed and indicated when the resident was served water, an individually packaged cup labeled "lemon flavored moderately thick honey consistency" was noted to be given.

On 03/18/24 an interview with Staff 6 (Health Service Director, RN) confirmed the physician orders were not being followed and Resident 6 was given honey thickened water.

* On 03/18/24 and 03/19/24 observations during lunch indicated Resident 6 was served regular sized pieces of lettuce and cut up tomatoes with dressing. On 03/21/24, the surveyor reviewed observations of the diet consistency with Staff 6 and she acknowledged Resident 6 did not receive a mechanical soft diet when the salad was served.

c. Secura Protection 10% cream (for redness/rash to groin) was being administered once a day without a current signed physician order.

The need to have signed physician orders in the resident's chart and follow all physician orders as prescribed was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Immediate Med cart audit was completed by the AED/Designee.

A complete audit of medication orders  will be completed initially and then monthly by the AED/ED/Nurse for parameters. Clear parameters will be outlined on the MAR for any medication requiring.

RN/Designee will educate med techs on medication parameters and actions, and notifying the RN on-call immediately of any vitals out of parameter to seek further direction.

Weekly medication cart audit will be completed on Wednesday by the AED/ED/Designee and will order any medications that are 7-14 days from running out and not on cycle fill.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner if a resident refused consent to an order for 1 of 2 sampled residents (# 6) who had documented refusals. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

The resident's MAR's dated 2/01/24 through 03/18/24, was reviewed and revealed facility staff documented Resident 6 refused the following orders:

* Sertraline (for depression) one time;

* Cavlon durable barrier cream (skin protection ) two times;

* Secura protective cream (redness/rash ) two times;

* Miconazole cream 2% (rash ) one time;

* Minerin cream (for dry, itchy skin) one time;

* Polyethylene glycol (bowel care ) one time;

* Remedy 2% Miconazole powder (for rash with moisture ) two times; and

* Acetaminophen (for pain) one time.

On 03/20/24  Staff 6 (Health Services Director, RN) confirmed there was no documented evidence the facility notified Resident 6's physician of the refusals.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (ED), Staff 6 and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings on 03/21/24.

Med techs inserviced on 3/25/2024 by AED of the notification to physicians of medication refusals.

The ED/Designee will pull the medication exception report at least 3 x's/week and follow up on any refusal of medications that Physician notification occurred. If it did not occur, the Med tech will be re-educated and the ED/Designee will notify the physician

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate, included resident specific parameters and staff instructions for 2 of 4 sampled residents (#s 1 and 6) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2023 with diagnoses including Parkinson's disease with dementia.

The resident's 03/01/24 through 03/18/24 MARs and physician's orders were reviewed.

a. The following PRN medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order:  

* Senexon-S and enema for constipation;

* Acetaminophen, morphine, and oxycodone for pain; and

* Lorazepam and quetiapine for anxiety/agitation.

b. Midodrine (hypotensive medication) lacked a reason for use and resident specific parameters on when to administer.

During an interview on 03/19/24 Staff 2 (Assistant ED) and Staff 9 (MA) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff. Staff 2 also confirmed the electronic MAR lacked a reason for use and resident specific parameters for midodrine.

The need to ensure resident's MAR was accurate and included resident specific parameters and staff instructions was reviewed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

2.  Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 6's 02/01/24 through 03/18/24 MARs, and physician's orders, dated 02/26/24 were reviewed.

a. A physician's order for haloperidol PRN for nausea and/or agitation/anxiety included instructions "Report to hospice for increased unusual somnolence, increased confusion or any other unusual changes." This information was not included on the MARs.

b. Silvasorb gel was noted on the MAR to be applied to "wound to back left side of head twice weekly". The February MAR had seven blanks and one occasion marked as "missed dose" on 02/05/24, and the March MAR had nine blanks. A current order and/or an order to discontinue was requested and no documented evidence was provided.  

On 3/19/24 Staff 17 (MA) indicated Resident 6 did not have a wound on his/her head and was not sure why the treatment was on the MAR.

The need to ensure accurate MARs were kept and included instructions for PRN medications was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

a complete audit of medication orders will be completed initially, and then monthly by the ED/AED/RN/Designee to ensure the correct diagnosis, reason for use, clearly outlined instructions on which med to utilize first (if there are multiple orders for the same type of drug) is outlined on the MAR

a complete audit of medication orders  will be completed initially and then monthly by the ED/AED/RN/Designee. Clear parameters will be outlined on the MAR for any medication requiring.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potential restraining qualities was assessed thoroughly by an RN, PT or OT prior to use and instruction to caregivers on the correct use and precautions of the device was included on the service plan for 1 of 1 sampled resident (# 4) who had bilateral half-length side rails in use. Findings include, but are not limited to:  

Resident 4 was moved into the facility in 09/2023 with diagnoses including dementia and Type II diabetes with long-term use of insulin.

Observation of the resident's bed during the survey on 03/20/24, revealed half-length, bilateral side rails on the bed.

On 03/20/24 at 12:05 pm, the surveyor requested assessment related to use of the side rails. Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) stated they just completed the assessment on 03/19/24 during the survey.

The 02/22/24 service plan was reviewed and there was no documentation of the side rails and instruction to caregivers on the use and precautions related to the devices

On 03/21/24, the lack of an assessment and documentation requirements for side rails use were reviewed with Staff 1 (ED), Staff 6 and Staff. No further information was provided.

a complete audit of medication orders will be completed initially, and then monthly by the ED/AED/RN/Designee to ensure the correct diagnosis, reason for use, clearly outlined instructions on which med to utilize first (if there are multiple orders for the same type of drug) is outlined on the MAR

a complete audit of medication orders  will be completed initially and then monthly by the ED/AED/RN/Designee. Clear parameters will be outlined on the MAR for any medication requiring.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) to accurately reflect all the ADLs for each resident, including the amount of staff time needed to provide care for 3 of 3 sampled residents (#s 2, 3 and 6). Findings include, but not limited to:

1. Resident 2 was moved into the facility in 01/2022  with diagnoses including dementia.

Resident 2's 02/22/24 service plan was reviewed, observations were made of the resident and interviews were conducted with staff. The time noted for the following ADL activities that staff provided for Resident 2 was not accurate or not included on the resident's ABST:

* Eating assistance;

* Bowel and bladder management; and

* Additional care services including multiple staff required to assist with incontinence care and completing tasks.

The need to have all required ADLs on the ABST with the amount of staff time needed to provide care was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 08/2023  with diagnoses including dementia with mood disorder.

Resident 3's record was reviewed, observations were made of the resident, and interviews were conducted with facility care staff. The time noted for the following. ADL activities that staff provided for Resident 3 was not accurate or not included on the resident's ABST:

* Monitoring behavioral conditions or symptoms; and

* Ensuring non-drug interventions for behaviors

The need to ensure the ABST addressed all required ADL's for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) on 03/21/24. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 08/2019 with diagnoses including dementia.

Resident 6's record was reviewed, observations were made of the resident, and interviews were conducted with facility care staff. The time noted for the following ADL activities that staff provided for Resident 6 were not accurate on the resident's ABST:

* Monitoring for physical conditions or symptoms.

The need to ensure the ABST addressed all required ADL's for each resident and the amount of staff time needed to provide care was discussed with Staff 1 (ED) and Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Supportive Device Assessments to be completed quarterly by the RN.

Audit completed on 3/19/2024 by RN for supportive Devices. Supportive device (bed rail) assessment completed by RN on 3/20/2024, documented and conversation had with POA explaining risks/benefits of device.

RN/designee will monitor expiration dates of Supportive Device assessments and update quarterly with service plans

All Management Team members were educated on supportive/restraining quality devices by the VP of Clinical Operations on 4/2/2024, to include notification to RN/ED/AED if items are noted.

.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 11, 16, 23, and 24) completed and documented training in First Aid and abdominal thrust within 30-days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 03/20/24 and revealed the following:

* There was no documented evidence Staff 11 (MA), Staff 16 (MA), Staff 23 (CG), and Staff 24 (CG), hired 02/04/20, 12/20/23, 11/21/23, and 01/05/24, respectively, completed training in First Aid and abdominal thrust within 30-days of hire.

The need for staff to complete all required training within the specified time frames was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

Employee File audit completed 3/28/2024 by BOM and Vice President Human Resources

All staff will be caught up on pre-service training. BOM will track and provide reminders.

BOM Will track training with support of ED and ensure it is completed. Staff that do not have trainings completed timely will be removed from the schedule until training is completed.

Orientation checklists will be provided to all staff upon hire. The BOM will track that these are completed within 3 working days and that the AED/ED/designee has signed off, and will place in employee files and upload into ALIS under the staff profile.

The BOM/Designee will track annual training requirements and ensure they are completed.

The BOM/designee will audit 10% of emplyee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

The previous six months of fire drill and fire and life safety training records were reviewed on 03/20/24 with Staff 1 (ED)  and Staff 3 (Maintenance Director). The following deficiencies were identified:

a. Fire Drills:

* Fire drills were only conducted on 01/26/24, 02/12/24 and 02/29/24, not every other month as required.

* The facility was not relocating residents from the simulated fire area. Therefore, there was no documentation of:

- The escape route used;

- Problems encountered, comments relating to residents who resisted or failed to    participate in the drills;

- Evacuation time-period needed;

         - Evidence alternate routes were used during fire drills; and

- Number of occupants evacuated.

* Staff interviewed did not know the designated point of safety.

b. Fire and life safety training for staff:

* The facility was not consistently providing fire and life safety training for staff on alternate months as required.

The need to ensure fire drills and fire and life safety training was conducted per the rules was reviewed with Staff 1 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. No further information was provided.

MTD will be educated by ED/VP Environmental Operations on expectations of fire drills and requirement of bi-monthly training topics.

The VP of Environmental Operations and Regional Maintenance support will educate all managers on how to conduct a fire drill.

Fire Drills and every other month education will be tracked utilizing the appropriate forms and uploaded into TELS. Fire drills will be reported through the monthly CQM meeting.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on fire and life safety procedures within 24 hours of admission and at least annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed with Staff 1 (ED) on 03/20/24 and the following deficiencies were identified:

* There was no documented evidence of instruction to residents on general safety procedures, evacuation methods, responsibilities during a fire, and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission; and

* There was no documented evidence of fire and life safety training provided to residents at least annually.

The need to ensure residents received fire and life safety training within 24 hours of admission and at least annually was discussed with Staff 1 and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

All resident fire safety training will occur by the MTD by 4/15/2024

All residents will receive fire training upon move in with contract signing by the ED/MTD/Designee.

Maintenance Director will schedule annual resident fire training in TELS to occur every April.

The results of this annual training will be reported to the CQI committee every year in April.

Based on 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 C513.  

C 455

to meet substantial compliance refer to plan below

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

The facility was comprised of one building, divided into four separate houses, each house had lockable entry doors. The MCC was toured on 03/19/24 at 11:00 am. The following areas were observed to need cleaning and/or repair:

a. Facility wide:

* Build up of brown and green debris was along the top of the wood perimeter of the outdoor seating area at the main entrance;

* Dead plants were in the planters at the entryway;

* Build up of debris was on the outdoor light fixtures at the main entrance;

* Florescent lights throughout the interior of the facility contained dead insects;

* Build up of dust and debris was in the square ceiling vents; and

* Handrails were scraped and gouged with bare wood exposed.

b. Flower House:

* Wall under the menu board had scuffed and chipped paint;

* Gouges and white paint were throughout the middle of the interior wall of the dining area;

* Missing light cover was above fire extinguisher; and

* Interior door to the right of entrance had chipped paint.  

c. Lighthouse House:

* Exposed nail head was in the wood of perimeter of television area;

* Entry way door had scuffs and scrapes; and

* Door to the courtyard had paint chips and gouges.

d. Mountain House:

* Brown staining to ceiling was outside of the main entrance.

The surveyor toured the environment with Staff 3 (Maintenance Director) on 03/20/23 and reviewed findings with Staff 1 (ED). They acknowledged the above areas needed to be cleaned and repaired.

VP Environmental Operations/Regional maintenance support, and the Maintenance Director will work in-house and with vendors to address all items noted.

Regional Maintenance support will educate ED/MTD on CBC walkthrough form.

The MTD/ED will conduct a monthly walk through utilizing the CBC Environmental Tour form and identify/fix concerns immediately

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair and was free of odors. This is a repeat citation. Findings include, but are not limited to:

The facility was comprised of one building, divided into four separate houses, each house had lockable entry doors. The MCC was toured between 07/01/24 at 11:40 am and 07/03/24 at 9:30 am. The following areas were observed to need cleaning and/or repair:

a. Flower House:

* Wall under the menu board had scuffed and chipped paint; and

* Pervasive urine odors throughout cottage, concentrated in living room.

d. Mountain House:

* Pervasive urine odors in living room and room 207.

The surveyor toured the environment with Staff 36 (Senior Maintenance Director) on 07/02/24 and reviewed findings with Staff 34 (Operations Specialist) and Staff 35 (Regional Director of Operations). They acknowledged the above areas needed to be cleaned and repaired.

a- area identified in flower house under menu board being scuffed and chipped of paint.

MTD/Designee will have the area in Flower house under the menu board repaired by

___________8/2/2024________.

d- Urine oders throughout including concentrated area in Mountain house living room and 207

1.MTD/Designee will have the carpets cleaedf in affected areas of odors by __8/5/2024____

All staff will be educated by the  ED/Designee on environmental issues to report immediately to the MTD/ED/Designee by 7/31/2024

ED/MTD/Designee will conduct weekly walkthroughts x 2 months, every other week x 2 months, and monthly ongoing using the CBC checklist to identify areas that are in need of repair and/or cleaning

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C150, C200, C231, C361, C372, C420, C422, and C513.

Refer to C150, C200, C231, C361,C372, C420, C422, and C513

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C513.

Z142- refer to plan of correction above

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 16, 23, and 24) had documentation of completed orientation, 3 of 3 sampled newly-hired direct care staff (#s 16, 23, and 24) completed pre-service dementia training prior to performing any job duties, 12 of 14 direct care staff (#s 9, 16, 17, 19, 23, 24, 26, 27, 30, 31, 32, and 33) completed demonstrated competency in all required areas within 30-days of hire, and 3 of 3 tenured staff (#s 4, 11 and 21 ) completed the required infectious disease training annually. Findings include, but are not limited to:

The facility's training records were reviewed on 03/20/24 and the following was identified:

a. There was no documented evidence Staff 16 (MA) and Staff 24 (CG), hired 12/20/23 and 01/05/24, respectfully, completed any of the required pre-service orientation topics prior to beginning their job duties.

Additionally, there was no documented evidence Staff 23 (CG), hired 11/21/23, completed the following pre-service orientation topics prior to beginning their job duties:

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures; and

* Food handler's certificate.

b. There was no documented evidence Staff 16, 23, and 24 completed pre-service dementia training courses in any of the required training topics prior to beginning their job duties.

c. There was no documented evidence Staff 9 (MA),16, 17 (MA), 19 (MA), 23, 24, 26 (MA), 27 (MA), 30 (MA), 31 (MA), 32 (MA), and 33 (MA), hired between 02/04/20 and 01/05/24, demonstrated competency in all required areas within the first 30-days of hire.

On 03/20/24 at 1:05 pm, the survey team informed Staff 1 (ED), Staff 6 (Health Services Director, RN), and Staff 7 (Vice President of Clinical Operations) that staff training and competency documentation had been reviewed and lacked the required documentation. Survey expanded the sample population for staff competency training to include the additional 10 MAs (Staff 9, 17, 19, 23, 26, 27, 30, 31, 32, and 33) identified to have passed medications.

At 1:55 pm, Staff 1 provided documentation of demonstrated competencies for Staff 11 (MA) and Staff 29 (MA), 2 of the 14 staff competencies requested.

During interviews with multiple direct care staff, it was determined the facility had a system for training and completing staff competencies but lacked an effective way to document the training.

On 03/21/24 at approximately 10:05 am, Staff 1, Staff 6, and Staff 7 were informed all MAs must demonstrate competency in their assigned job duties before continuing to administer medications. The survey team requested an plan of correction (POC) that addressed the medication system and staff training. At approximately 11:30 am, a POC was submitted to the survey team. At approximately 2:30 pm, the POC was accepted.

d. There was no documented evidence Staff 11 completed the required number of annual in-service training hours, including at least six hours of dementia care topics.

e. There was no documented evidence Staff 4 (Activity Assistant), Staff 11, or Staff 21 (Housekeeping), hired 02/20/17, 02/04/20, and 01/20/21, respectively, had completed the required annual infectious disease prevention training.

The need to ensure newly hired direct care staff completed all pre-service orientation and training topics prior to beginning any job duties, demonstrated competencies in the required areas within 30-days of hire, and that the required infectious disease training was completed annually was discussed with Staff 1, Staff 6, and Staff 7 on 03/21/24 at 2:55 pm. They acknowledged the findings.

Refer to C372

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

During  the re-licensure survey, conducted 03/18/24 through 03/21/24, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to C252, C260, C270, C280, C282, C290, C295, C300, C302, C303, C305, C310, and C340.

Situations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. Immediate plans of correction were requested in the following area:

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

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

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

The facility put immediate plans of correction in place during the survey and the situations were abated.

Refer to C150

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 3 of 4 sampled residents (#s 1, 2 and 3). Findings include, but are not limited to:

1. Resident 2 resided on the memory care unit and had been identified to require meal assistance. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs.

Observations performed during the survey at meal times revealed the resident required frequent cueing and hands-on assistance to eat meals. The resident was able to eat most of his/her meals with staff assistance. During observations on 03/18/24 and 03/20/24, the resident was not provided with snacks or fluids between the morning and noon meals.

The resident had experienced significant weight loss over the past six months and was dependent on staff to meet nutrition and hydration needs. The service plan did not address hydration needs and lacked information on interventions to monitor weight changes.

The lack of an individualized nutritional plan was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

2. Residents 1 and 3 resided on the memory care unit and had been identified to require meal assistance including cueing and set up. The current service plan and temporary service plans were reviewed during survey and lacked an individualized nutrition and hydration plan based on needs.

The lack of an individualized nutritional plan was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. They acknowledged the findings.

An audit of all evaluation dates will be completed

An audit of all evaluations will be completed to ensure the following required items are answered and service planned: nutrition/hydration; activities; behavioral plans;

Culinary staff will ensure the hydration stations are refreshed two times per day

All staff were educated on nutrition/hydration to include all residents being offered appropriate snacks per their diet  times per day in addition to meals with fluids (10am, 3pm, 7pm)

Based on observation, interview, and record review, it was determined the facility failed to develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 3, and 6) whose activity evaluations were reviewed. Findings include, but are not limited to:

Service plans and evaluations were reviewed for Resident 1, 2, 3, and 6. Observations and interviews were completed between 03/18/24 and 03/21/24. The following deficiencies were revealed:

There was no documented evidence individualized activity plans were developed based on the residents' activity evaluations that reflected each resident's activity preferences and needs.  

During an interview on 03/20/24 at 9:27 am, Staff 4 (Activities Director) confirmed she was unaware an individualized activity program needed to be developed for each resident.

The facility failed to develop individualized activity plans based on each resident's activity evaluation.

The need to ensure the facility developed individualized activity plans for each resident was discussed with Staff 1 (ED), Staff 6 (Health Services Director, RN) and Staff 7 (Vice President of Clinical Operations) on 03/21/24. The findings were acknowledged.

Life Stories will be obtained for all residents by the PGD/AED/ED/Designee.

PGD/ED will give a list of resident specific likes/dislikes for activities to the ED/RN to update service plans.

Staff to be educated on engagement kits, not using TV for activity by the PGD/ED/National Director of Programming.

Service plans will be updated by the AED/ED/RN/Designee to reflect activity/engagement plans.

The ED/AED/HSD/Designee will provide ongoing audit of service plans for activity plans with move in, change in condition, and at least quarterly.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked outside their rooms. Findings include, but are not limited to:

During the survey, observations of resident rooms in Flower house revealed rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Direct care staff each carried a key which could open all residents' rooms.

Observations on 3/18/24 identified two residents attempted to open the door to their apartments but the doors were locked. One resident left and returned five minutes later and attempted to enter his/her room again. The surveyor did not observe staff unlock the door for either resident.

On 3/18/24 an interview with Staff 28 (CG), indicated that all the residents' doors were locked in Flower house because a resident liked to take things. Staff 28 stated only two residents in Flower house had their own keys to their rooms.

On 03/21/24, the need to ensure residents were not locked outside their rooms was discussed with Staff 1 (ED), Staff 6 (Health Service Director, RN) and Staff 7 (Vice President of Clinical Operations). They acknowledged the findings.

Staff will be educated by the ED/Designee that only doors where the resident has been assessed to have a key and appropriately use the key and has been service planned can be locked when residents are not in their room.

The leadership team will audit this at least 3 x's/week x 1 month, 2 x's/week x 1 month, and then at least weekly when rounding and note on Resident Care Connections and provide in the moment, on-going education.