Print Inspection: HLWC

The findings of the change of ownership survey conducted 05/23/22 through 05/25/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, 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

The findings of the first revisit to the re-licensure survey of 05/25/22, conducted 08/31/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

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 revisit to the re-licensure survey of 05/25/22, conducted 12/01/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to prepare and serve food in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

A tour of the kitchen on 05/23/22 and the dining room on 5/25/22 showed the following areas in need of cleaning or repair:

A. Main Kitchen

* Scratches and chips in the tile flooring, creating an uncleanable surface; and

* Broken lower shelving on each of three metal carts, including one supported by cans of food and one supported by a cardboard box.

B. Dining Room

* Worn varnish on beverage and snack cabinet countertop, exposing bare wood and creating an uncleanable surface; and

* Buckling and separating vinyl flooring, including a separated area approximately 24" x ½", exposing underflooring.

C.  Refrigerator/freezer in the upstairs kitchen

* Drips of dark purple sticky substance on walls of freezer and frozen to the outside of food packages.

Findings were discussed with Staff 1 (Administrator) on 05/24/22 and 05/25/22. She acknowledged the findings.

Z142/C240 Resident Services Meals, Food Sanitation Rule

1) Daily inspection of the kitchen, dining room, flooring and refrigerator (upstairs) will be conducted by the Administrator and Chef.  Administrator will submit the finding to the owner for a plan to repair.

* Broken lower shelving on three metal carts were fixed on 5/26/2022.

* Worn varnis on beverage and snack countertop fixed 6/20/22.

* Refrigerator (upstairs) cleaned as of 5/27/2022 (no food items stored)

2} Daily communication with the Chef to assure things are working and functioning well.

3} Administrator will submit weekly reports to the owner of the Kitchen, dining room, and flooring of the daily inspections of areas needed to be repair.

4} Administrator

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.

a. Observations of the resident, interviews with staff, service plan dated 03/08/22 and Temporary Service Plans (TSPs) were reviewed. The service plan was not reflective of the resident's current status or lacked caregiving instructions in the following areas:

* Toileting assistance;

* Frequency of incontinent checks;

* Two person transfer assistance at times;

* The ability to manage ambulation and mobility independently;

* Mobility device currently used;

* Dining;

* Behavioral issues and interventions;

* Duties of private caregivers;

* Activities; and

* Fall interventions.

b. On 05/13/22, a TSP was initiated noting Resident 1 had a new roommate. The TSP was not resident specific as it directed staff to "take all vital signs" and "push fluids."

The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs, updated with changes, and provided clear direction to staff regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia with behavioral disturbance and history of stroke.

Observations of the resident, interviews with staff, and review of the service plan dated 05/19/22, indicated the service plan failed to reflect the resident's current care needs relating to oral care.

The need to ensure service plans were reflective of the resident's status and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C260 -Service Plan

1} Health Service Director will complete a initial evaluation, 30 day and quaterly as well as Significant Change of Condition for any resident.  The Initial evaluation tool has been updated to reflect some changes in collecting accurate information about a resident to build a personalized Service Plan for the resident so that family understand the care needs provided. Staff will be educated about each Service Plan implemented to understand and follow.Health Service Director to communicate any updates or changes to the Service Plan to family and staff.

2} Service Plan will have a three check system so that any inconsistencies will be noted and fixed.

3} Service Plans are to be reviewed after 30 days and quaterly and at Change of Condition. Monthly audits will be conducted.

4} Service Plans will be written and reviews by Health Service Director, RN and Administrator.   

Based on observation, interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed for changes of condition including resident specific instructions communicated to staff on each shift, updated the service plan and monitored the resident consistent with the  evaluated needs for 1 of 2 sampled residents (# 1) who experienced changes of condition. Resident 1 had repeated falls with injury. Findings include, but are not limited to:

Resident 1 was admitted to the MCC in 03/2021 with diagnoses including history of falls and dementia.  

During the acuity interview, Resident 1 was identified as a fall risk and at times required two people for ADL assistance.  

The 10/27/21 service plan was reviewed and the following fall interventions were documented:

* Room should be free of clutter, no cords should be out and lighting should be sufficient for ambulating;

* Provide safety checks when in room especially at night;

* Encourage the resident to stay in common area for better visual monitoring;

* Use wheelchair for long distance transport;

* Always turn pressure alarm on. Notify MT or nurse if alarm is not functioning well or low on battery;

* Remind the resident to look behind him/her first before sitting;

* Remind to always use front wheel walker for short distance ambulation;

* Use one person assist for transfers;

* Provide and remind to use call system at all times;

* Ensure s/he is wearing proper footwear for all mobility; and

* Leave bathroom lights on at night.

The resident record was reviewed and noted nine falls between 10/25/21 and 05/21/22.

The service plan was updated on 12/16/21 and 3/8/22. The fall interventions remained the same and noted the addition of a private caregiver from 2:00 pm - 6:00 pm daily.

Temporary service plans dated 10/25/21 through 5/21/22 noted continued safety checks every one to two hours while the resident was in bed/apartment and chart interventions to prevent falls from reoccurring.

Observations of Resident 1 throughout the survey showed light green bruising across his/her face, over the bridge of the nose and below the eyes. The resident's upper lip was swollen on the left side.

On 05/25/22 at 1:09 pm, Staff 10 (CG) stated fall interventions included not laying the resident down in his/her room, the resident was kept in the common areas and had safety checks during the nights. Staff 10 stated the resident did not use a walker, did not have a pressure alarm but did have a "baby monitor."   

On 05/25/22 at 1:26 pm the resident's room was observed. The alarm component was located under the bed. The pressure pad component was observed between the fitted sheet and mattress, with the alarm cord disconnected. When the alarm was reconnected to the pressure pad, it was not functional when tested. There was also a "baby monitor" located to the left of the resident's television.  

On 05/25/22 at 1:32 pm, Staff 3 (RCC) confirmed the audio component of the "baby monitor" was located in the medication room.

On 05/24/22 and 05/25/22, both Staff 1 (Administrator) and Staff 2 (Health Service Director) reported the resident often disconnects the alarm from the pressure pad. They were informed the pressure alarm was not in working order on 05/25/22.

Resident 1 was identified to be at risk for falls and experienced multiple injury falls. There were multiple fall prevention interventions that were not reviewed with each fall to determine if they were in place and/or continued to be effective and the resident continued to fall. Resident 1's falls were reviewed with Staff 1 and Staff 2 on 05/25/22. No additional information was received.

Z162/C270--Change of Condition

1} Staff will document any noted changes to resident/s condition in QMAR under chart notes.  Health Service Director will monitor chart notes daily and implement temporary service plan change for short term change of condition or long term change of condition and initiate an assessment.  Health Service Director will monitor Change of Condition through resolution.

2} Staff will be trained and educated on reporting changes to baseline on a monthly inservice.  Health Serive Director will monitor Alert Charting and resident changes at least weekly and or through resolution.

3) Monthly audits will be conducted that will include monitoring Change of Condition and follow through

4} Health Services Director

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia and depression.

The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed:

* Lexapro (for depression) not administered on 05/10/22 and 05/12/22 due to the medication not being available;

* Daily bowel monitoring parameters were not followed;

* PRN bowel medications were not administered per orders; and

* Lidocain cream (for pain) was not administered on 12 occasions due to the medication not being available.

3. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.

Resident 3's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed. The physician's order reflected the following parameters for constipation:

* Step 1 - Milk of Magnesia;

* Step 2 - bisacodyl tablets; and

* Step 3 - bisacodyl suppository.

The parameters on the MAR directed staff to record bowel movements every shift, and to follow the bowel protocol if the resident had no bowel movement for two days. Per parameters, Resident 3 should have been administered Milk of Magnesia on the following dates and times:

* Between 2:00 pm and 10:00 pm on 05/05/22; and

* Between 2:00 pm and 10:00 pm on 05/10/22.

Documentation on the MAR revealed bisacodyl tablets were administered on 05/05/22 at 12:26 pm and 05/10/22 at 12:16 pm.

The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 06/2019 with diagnoses that included dementia with behavioral disturbance and history of stroke.

The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and the following orders were not carried as prescribed:

* PRN Milk of Magnesia (for constipation) nightly, for no bowel movement in 48 hours or more was not administered on 04/11/22, 04/15/22, 04/23/22 and 05/20/22 per parameters;  

* PRN bisacodyl suppository (for constipation) daily, if no bowel movement greater than three days, was administered on 04/12/22 after two days of no bowel movement;

* Between 04/21/22 and 04/26/22 the resident went five days with no bowel movement and no PRN bowel medications;

* Scheduled guaifenesin syrup (for cough), three times daily for seven days was administered for eight days plus one dose; and

* Scheduled nystatin (for candidiasis fungal infection of the oropharynx) by mouth four times daily for 10 days with specific direction to swish in mouth for at least 30 seconds before swallowing, however, a progress note dated 05/21/22 by Staff 6 (MT) states "Swab [his/her] mouth with the new med, [the resident is] unable to swiss [sic] the new med." Staff 6 confirmed the resident was not administered the medication per physician's orders on 05/24/22 at 12:10 pm.  

The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C303--Systems: Treatment Orders

1} Health Service Director will make sure Med Tech are following written orders as prescribe by Physicians.  Med Tech training will be held monthly to go over Physicians orders, Medication pass, medication parameters, bowel protocal medications, PRN and treatments.  

2} Med Tech training was held on 6/10/2022 to go over the med tech role and Medication Management.  Understanding the importance of following orders and treatments.  Know the protocals, policy and procedures of making sure that medications and treatments are administed as order.

3} HSD will conduct a Monthly Audit and quaterly audits by our community Pharmacy (PharAmerica)

4} Health Service Director

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for all medications the facility was responsible to administer for 1 of 2 sampled residents (#4) whose orders were reviewed.  This is a repeat citation.  Findings include, but are not limited to:

Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia.

Signed physician orders dated 08/26/22 noted the following medications were to be administered to Resident 4:

*Hydralazine 25 mg tag three times daily (for hypertension); and

*Sotalol 80 mg twice daily (for atrial fibrillation).

The 08/26/22 through 08/31/22 MAR was reviewed and noted both medications had been discontinued on 08/25/22.  There was no documented evidence the resident received the medications as ordered from 08/26/22 through 08/31/22.  

During an interview on 08/31/22 at 4:10 pm, Staff 1 (Administrator) and Staff 12 (Health Services Director) acknowledged the medications were not being given as ordered.

C303--Systems: Treatment Orders

1} Health Service Director and Resident Care coordinator  will make sure Med Tech are following written orders as prescribe by Physicians.  Med Tech training will be held monthly to go over Physicians orders, Medication pass, medication parameters, bowel protocal medications, PRN and treatments.  

2} Med Tech training was held on 9/8/2022 to go over the med tech role and Medication Management.  Understanding the importance of following orders and treatments.  Know the protocals, policy and procedures of making sure that medications and treatments are administed as order.

3} HSD and Resident care coordinator will conduct a Monthly Audit and quaterly audits by our community Pharmacy (PharAmerica)

4} Health Service Director and RCC

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear parameters for administration of prescribed medications for 2 of 3 sampled residents (#s 1 and 3) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.

The 04/01/22 through 05/23/22 MARs, TARs and physician orders were reviewed and showed the following inaccuracies:

* On 05/09/22, staff documented they did not attempt three non-drug interventions prior to administering the PRN psychotropic, but when interviewed, they stated they did attempt the interventions;

* Scheduled Lidocaine cream (for pain) had parameters to "apply topically to affected area 3 - 4 times daily," and

* PRN albuterol (for shortness of breath or wheezing) to "inhale 1 - 4 puffs by mouth."

2. Resident 3 was admitted to the facility in 03/2021 with diagnoses including dementia.

The resident's 05/01/22 through 05/23/22 MAR, TAR and physician's orders were reviewed and showed the following inaccuracies:

* For the daily bowel monitoring parameters, the note directed staff to administer Miralax for no bowel movement in two days. The physician's order directed staff to administer Milk of Magnesia if the resident did not have a bowel movement in two days;

* The directions to staff for the bisacodyl tablets stated, "Step 2" but the order note stated, "This is Step 1 of the Bowel Protocol. If not relieved in 24 hours, go to step 3;"  

* Milk of Magnesia was listed as "Step 1" and directed staff to administer the medication in three days if the resident had not had a bowel movement; and

* The TAR reflects bisacodyl suppository to be "Step 3" and to administer if "constipation [was] not relieved with bisacodyl oral tablets," thus not having clear parameters for the four PRN bowel medications.

The need to ensure the MARs were accurate and included clear parameters for administration of prescribed medications was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z162/C310--Medication Administration

1} Health Service Director will audit the QMAR weekly to ensure the consistance of medication pass by Med Tech.  Weekly audits will include, PRN given, parameters followed, interventions offered before administer the medication, and audit for consistancy with following orders.

2} Med Tech training was held on 6/10/2022 to go over bowel protocol, following orders, following treatment as prescribe by PCP.

3} Health Service Director will conduct weekly audits and community Pharmacy (PharAmerica) quarterly audits.

4} Health Services Director

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 2 of 2 sampled residents (#s 4 and 5) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2020 with diagnoses including Alzheimer's dementia.

Resident 5's 08/01/22 through 8/30/22 MAR was reviewed during the survey.

The following medications were documented as being administered at 8:00 am daily:

* Calcium Carbonate;

* Losartan;

* Memantine;

* Metformin;

* Sertraline; and

* Vitamin D3.

The following medication was documented as being administered at 7:00 am daily:

* Levothyroxine.

In an interview with Staff 6 (MT) on 08/31/22 she reported that the resident slept late and that morning medications were regularly given between 10 am and 11 am.

The need to ensure MARs were accurate was discussed with Staff 1 (Administrator) on 08/31/21. She acknowledged the findings.

2.  Resident 4 was admitted to the facility in 08/2022 with diagnoses including Lewy body dementia.

Resident 4's 08/01/22 through 08/31/22 MARs were reviewed and lacked resident specific parameters to guide unlicensed staff in the following areas:

*Acetaminophen 325mg 1 tablet PRN pain;

*Acetaminophen 325mg 2 tablets PRN pain;

*Morphine Sulfate 5mg PRN moderate pain; and

*Polyethelene Glycol PRN constipation.

Resident specific parameters for pain and bowel care medication was reviewed with Staff 1 (Administrator) and Staff 12 (Health Services Director) on 08/31/22 at 4:10 pm.  Staff acknowledged the findings.

C310--Medication Administration

1} Health Service Director and Resident Care Coordinator will audit the QMAR weekly to ensure the consistance of medication pass by Med Tech.  Pre popping is unacceptable. Med Tech is to follow the medication pass according to the time stated in the MAR. Weekly audits will include, PRN given, parameters followed, interventions offered before administer the medication, and audit for consistancy and accuracy with following orders.

2} Med Tech training was held on 9/8/2022 to go over bowel protocol, following orders, following treatment and medication orders as prescribe by PCP.

3} Health Service Director and Resident Care Coordinator will conduct weekly audits and community Pharmacy (PharAmerica) quarterly audits.

4} Health Services Director and RCC

Based on interview and record review, it was determined the facility failed to conduct drills every other month and failed to include required components on fire drill records. Findings include, but are not limited to:

Review of fire and life safety records for December 2021 through May 2022 identified the following:

1. Two fire drills had been completed during the six-month time frame reviewed.

2. Fire drill records lacked the following components:

* Location of simulated fire origin;

* Escape route used;

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

* Evidence alternate routes were used during fire drills; and

* Number of occupants evacuated.

The need to ensure the facility conducted fire drills every other month and included documentation of all required components was discussed with Staff 1 (Administrator) on 05/24/22 at 2:00 pm. She acknowledged the findings.

Z142/C420--Fire and Life Safety:

1} Administrator will conduct unannouced Fire Drill every other month.  Fire and Life Safety training will be provided alternate months.  Fire Drills will be conducted for each shift, Day, Swing and NOC. Fire and Life Safety trainings will be held alter months at the all staff meetings.  Administrator updated the Fire Drill and Fire and Life Safety form to reflect the missing information provided by the State Surveyors.  

2} Fire Drills will be conducted unannouced every other month by the Administrator.  This will include all three shift (Day, Swing, NOC) These Fire Drills will include the following

a.Date and time of day, b. Location of simulated fire orgin, c. The escape route used, d. Problems encountered and comments relting to residents who resisted or failed to participate in the drills, e. Evacustion time period needed. f. staff members on duty and participating, g. number of residents evacuated.Fir

3} Fire Drills every other month, Life and safety training on alternate months.

4} Administrator  

Based on interview and record review, it was determined the facility failed to re-instruct residents at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire. Findings include, but are not limited to:

On 05/24/22, this surveyor met with Staff 1 (Administrator) to review the facility's process and documentation for instructing residents on basic safety procedures. Staff 1 stated the facility did not have a process for providing instruction to residents at least annually in fire and life safety procedures.

Staff 1 stated she understood the requirements and would be able to implement a procedure for providing instruction to residents quickly.

Z142/C422-Fire and Life Safety Training for Residents

1} Administrator will meet with new resident and family members to go over fire drills and fire and life safety procedures.  Resident handbook will be updated to include the fire drill procedure and Fire and Life Safety procedure.  

2} The Administrator will audit training binder on a monthly basis to make sure that any new resident/s moving in is/are educated with the procdure.  The Administrator will conduct Fire and Life Safety training annually, in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire.  Will invite families to attend if avaialble.  Training can be in form of watching a Fire and Life Safety Video or a guest speaker from the Fire Department.

3} The Administrator will conduct this for every new move in and annually.

4} Administrator

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 C 303, C 310, Z 155 and Z 162.    

C455-Inspections & Investigations

1) Administrator and RCC will make sure the information needed is available at all times.

2) Administrator and RCC will make sure that all records, documentations, self report, IR, resident SP, application procedures and other necessary activities are made avaialble to the department upon request. Accuracy and consistency of reporting concerns to the proper autnority to rule out any abuse and neglect in the community.  Consistency of communications with PCP, families and third party agencies on a daily basis.

3)Administrator and RCC will audit records on a day to day basis to make sure that all information gathered, documented and follow through.

4) Administrator and RCC

Based on observation and interview, it was determined the facility failed to ensure the grounds were orderly and free of litter and refuse, and garbage was stored in closed containers. Findings include, but are not limited to:

The facility grounds were toured on 05/25/22. There was refuse including cardboard boxes and a recliner observed in the front of the building, to the right by the smoking area.

The need to ensure the building exterior was kept orderly and free of litter and refuse was discussed with Staff 1 (Administrator) on 05/25/22. She acknowledged the findings.

Z142/C510-Gene Building Exterior

1} Administrator will walk the outside of the community to make sure it is free of trash.  Administrator will check to make sure the trash area is clean and free of trash on the ground.  Administrator will make sure that the overall look of exterior of the community is clean, clear and well kept daily.

2} Administrator will conduct walk through daily and report any exterior wear and tear or damages to the owner

3} Administrator will monitor daily through walk through when in the community.  Other days when not in the community will observe through outside cameras.

4} Administrator

* All items observed during the survery were removed on 5/25/2022.

* Remainder of the fence was put up by the neighbor on 6/6/2022

Based on observation and interview, it was determined the facility failed to ensure the design of the RCF supported special resident needs relating to the installation of handrails at one or both sides of resident-use corridors. Findings include but are not limited to:

The interior of the building was toured on 05/25/22 at 11:50 am. The corridor between the medication room and the conference room was lacking a handrail.

The need to ensure handrails were accessible to residents along corridors was discussed with Staff 1 (Administrator). She acknowledged the findings.

Z142/C511-General Building Interior

1} Administrator will conduct daily walk through of the community to make sure that common areas (Lobby, Living room, Dining room and hall ways are visible and accessible to residents and visitors when entering the doors to the main exntrace at the community.

2} Administrator will communicate to staff to report any damages or things out of place so that Administrator can follow up, document and communicate to the owner of a plan to replace or fix.

3} Administrator will conduct daily walk through.  Report the finding to owner on a weekly basis.

4} Administrator

* The side rail was installed on 6/16/2022 by the corridor between med room and the conference room.

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

Observation of the facility on 05/23/22 through 05/25/22 revealed:

* Gouges in baseboards throughout the facility;

* Scuffs and gouges along the corridors;

* The bottom of multiple room doors were scuffed;

* Multiple door frames had scuff marks on them; and

* Room 4's door frame had exposed wood that was rough to the touch.

The findings were reviewed with Staff 1 (Administrator) on 5/25/22. She acknowledged the findings.

Z513/C513-Doors, Walls, Elevators, Odors

1} Administrator will conduct a daily walk through of the community to check for wear and tear of the whole interior of the community.  Any findings is to report to the owner for a plan to repair.

2} Administrator will follow through with the daily walk through report and report findings to the owner on a weekly basis.  Owner will reach out to the contract maintenance staff to assist with getting repairs done.

3} Daily walk through will report to owner on a weekly baisis unless it is an ememrgency that is needed to fix immediately.

4} Administrator

* Touch up paint was completed 5/27/2022

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 C 240, C 420, C 422, C 510, C 511 and C 513.

Z142

Refer to C240, C420, C422, C510, C511, and C513

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 1 of 1 newly hired direct care staff (# 7) and annual training was completed and documented for 3 of 3 long-term direct care staff (#s 6, 9 and 10) whose training records were reviewed. Findings include, but are not limited to:

Training records were reviewed on 05/24/22.

Staff 7 (MT/CG) was hired on 02/15/22. Review of the facility training records revealed Staff 7 did not complete the following pre-service and competency training before providing care and services independently:

* Abuse reporting requirements;

* Environmental factors that are important to resident's well-being (e.g. noise, staff interactions, lighting, room temperature, etc.);

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;

* The use of supportive devices with restraining qualities in memory care communities;  

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Conditions that require an assessment, treatment, observations and reporting; and

* Other duties as applicable (Med pass, treatments).

Staff 1 (Administrator) reported on 05/25/22 the topics would be addressed and the competencies demonstrated would be documented later that evening when Staff 7 returned to work.

Staff 6 (MT/CG) was hired on 12/07/19, Staff 9 (CG) was hired on 01/11/19 and Staff 10 (CG) was hired on 09/16/19. Review of the facility training records revealed the following:

* Staff 6 did not complete six hours of annual training related to dementia care;

* Staff 9 did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care; and

* Staff 10 did not complete ten hours of annual training related to provisions of care in CBC.

The need to ensure all newly hired staff completed pre-service orientation and all veteran staff completed 16 hours of annual training was discussed with Staff 1 who acknowledged the findings.

Z155-Staff Training requirements

1} Staff members 6, 7, 9 and 10 will receive Oregon Healthcare Partner training and Compliance training by compliance date.  Competency checklists have been updated to include missing elements of training.

2} Facility will utilize trainings thare in Compliance with OAR to ensure staff receive training on relevant topics.   Administrator and RCC will go through the Orientation process with all new hires.  Provide Dementia training (through training video, Oregon Healthcare Partners (Free Training), Monthly staff inservice by Administrator or schedule vendor to provide training on relevant topics to make sure that our staff are properly trained.

3} Quarterly competency evaluations will be conducted to determine knowledge and understanding.

4} Administrator and Resident Care Coordinator

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired staff (#13) had documentation of completed orientation, pre-service dementia training and demonstrated competency in all required areas prior to working independently with residents.  This is a repeat citation.  Findings include, but are not limited to:

Staff 13 (CG), hired 08/03/22, training records were reviewed with Staff 1 (Administrator) on 08/31/22 and revealed the following:

a.  There was no documented evidence Staff 13 had completed orientation prior to performing any job duties in the following areas:

*Resident rights and values of CBC care;

*Abuse reporting requirements;

*Infectious Disease Prevention; and

*Fire safety and emergency procedures.

b.  There was no documented evidence Staff 13 completed the pre-service dementia care training prior to providing care and services independently.

c.  There was no documented evidence Staff 13 demonstrated competency in required areas prior to providing care and services independently.

During an interview with Staff 1 on 08/31/22, she verified the lack of training documentation.  Staff 1 stated the employee was a re-hire and new hire paperwork had been completed, however was unable to provide written documentation.

Z155-Staff Training requirements

1} Staff members and new hires will receive Oregon Healthcare Partner training and Compliance training by compliance date.  Competency checklists have been updated (using the CBC Caregiver Training Record Review) to include missing elements of training.

2} Facility will utilize trainings that are in Compliance with OAR to ensure staff receive training on relevant topics.   Administrator and RCC will go through the Orientation process with all new hires.  Provide Dementia training (through training video, Oregon Healthcare Partners (Free Training), Monthly staff inservice by Administrator and RCC or schedule vendor to provide training on relevant topics to make sure that our staff are properly trained. Staff members given information on how to access Oregon Healthcare Partners with the list of required classes to complete before start of emplyment.  

3} Quarterly competency evaluations will be conducted to determine knowledge and understanding.

4} Administrator and Resident Care Coordinator

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:

Refer to C 260, C 270, C 303 and C 310.

Z162-Compliance with Rules Health Care

Refer to C260, C270, C303, and C310

Based on 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:

Refer to C 303 and C 310.  

Z162

Refer to C303 and C310

2. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.

Resident 1's current service plan was reviewed during survey. The service plan lacked an accurate, individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.

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

1.  Resident 2 was admitted to the facility in 06/2019 with diagnoses including dementia and history of stroke.

Resident 2's current service plan was reviewed during survey. The service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (Administrator), and Staff 2 (Heath Services Director) on 5/25/22. They acknowledged the findings.

Z163-Nutrition and Hydration

1} Health Services Director will include a nutrition and hydration schedule to each resident's service plan. Initial evaluation form has been updated to asked more detail questions about favorite drinks (any juice, coffee, tea, soda pop (what kind) resident preferences.  Resident Social profile update to add resident likes and dislikes in regards to food and drinks. Information collected from these two tools will help develop a more detailed and personlize service plan for staff to read and understand.  

2} Facility will assign caregiver to specific residents daily to ensure that hydration and nutrition schedules are offered to each resident during waking hours.

3} Health Service Director will evaluate nutrition and hydration schedules monthly and implement any changes as needed.

4} Health Service Director

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

Though Resident 1, 2 and 3's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate.

There were no specific activity plans which detailed what, when, how and how often staff should offer and assist the residents with individualized activities.

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z164-Activities

1} Resident Social profile update to include the following: a. Past and current interests, b. Current abilities and skills, c. Emotional and social needs and patterns, d. Physical abilities and limitations, e. Identification of activities for behavioral interventions, f. Adaptations necessary for the resident to participate, g. Schedule and planned events (entertainments, outings) h. Activities for enjoyments or those that may help diffuse a behavior, i. Activities that encourage positive relationship between residents and staff (life story, reminiscing, music) j. Sensory stimulation activities, k. Physical activities that enhance or maintain a resident's ability to ambulate or move, l. Outdoor activities that interest a resident.

2} Administrator will meet with Activitiy Director to go over the Resident Social Profile and plan activities appropriate for each resident as a group or individual.  Resident Social Profile will be given to Health Service Director to implement the information collected into resident Service Plan.

3} Monthly audits will be conducted by Administrator and also on any new admission.

4} Administrator

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 1 and 3) with documented behaviors. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2021 with diagnoses including dementia.

Resident 1's record documented behaviors including agitation, yelling and putting himself/herself on the floor for attention.

An interview with Staff 10 (CG) on 05/25/22 at 1:09 pm revealed the service plan was not reflective of the interventions that were more successful with the resident. She identified the resident enjoyed any activity and taking the resident to the restroom. Staff 10 stated the resident responded well to constant one on one attention, but staff didn't have the time to be able to do that. She also stated that the intervention for staff to let the resident rest in his/her room was not safe due to being a high fall risk.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including dementia.

The resident's service plan, dated 04/14/221, did not address any behaviors, thus lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.

Staff 10 confirmed Resident 3's behaviors included refusing care. The resident preferred some staff over others, so in order for the resident to consent to care (e.g. assistance with ADLs), staff would switch to someone the resident responded to positively.   

The need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 05/25/22. They acknowledged the findings.

Z165--Behavior

1} Initial Evaluation form updated to add more detail questions in regards to behaviors and interventions.  Health Service Director is to collect as many information about past behavior and recent behaviors with solutions that was successful in the past.  Health Service Director is to develop his/her service plan under section Emotion Health/Behavior Issues, plan interventions with a behavior presented in the past and/or recent behaviors.  List each behavior with interventions that are successful and interventions that were not successful.  

2} An inservice was held on 6/10/2022 to train staff on resident behaviors, what intervention works and what interventions did not work.  Every resident reacts different.  

3} Monthly inservices for all staff on relevant topics to resident behaviors, monthly service plan audits.

4} Administrator and Health Service Director