Print Inspection: IQ8K

The findings of the re-licensure survey conducted 04/10/23 through 04/13/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 04/13/23, conducted from 07/26/23 through 07/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the 2nd revisit to the re-licensure survey of 04/13/23, conducted on 09/22/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

3. Resident 3 was admitted to the facility in 10/2022 with diagnoses including renal failure.

The resident's service plan, dated 12/20/22, was reviewed and an interview with the resident was conducted on 04/12/23. Resident 3's service plan did not provide clear instruction to staff in the following areas:

* Medications the resident self-administered;

* Pain medications;

* Powered mobility device;

* Instructions to staff on dialysis days; and

* Right side port instructions relating to blood pressures.

On 04/13/23 at 1:27 pm, Staff 2 (RN, Health Services Director) confirmed the service plan had not been updated quarterly.

The need to ensure service plans were updated quarterly and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 2 on 04/13/23. They acknowledged the findings.

4.  Resident 4 was admitted to the facility in 10/2022 with diagnoses including chronic pain, nerve pain and insomnia.

The resident's service plan, dated 10/29/22, was reviewed. On 04/13/23 at 1:27 pm, Staff 2 (RN, Health Services Director) confirmed the service plan had not been updated quarterly.

The need to ensure service plans were updated quarterly was discussed with Staff 1 (ED) and Staff 2 on 04/13/23. They acknowledged the findings.

5.  Resident 5 was admitted to the facility in 12/2018 with diagnoses including cognitive disorder. The resident was reported as receiving Hospice services.

The resident's current service plan, dated 04/06/23, was reviewed, observations were made and interviews with caregivers were conducted on 04/11/23. Resident 5's service plan did not provide clear instruction to staff in the following areas:

* Staff to do all meal ordering for the resident;

* The resident's preferred food choices;

* Adaptations needed for beverage consumption;

* Frequency of visits by the hospice bath aide; and

* Current ability to express needs and wants.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) Staff 2 (RN, Health Services Director) and Staff 3 (RCC) on 04/13/23. They acknowledged the findings.

6. Resident 6 was admitted to the facility in 04/2020 with diagnoses including type two diabetes.

Observations were made, interviews with the resident and staff were conducted and the resident's most current service plan, dated 10/19/22, was reviewed. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Recent hospital stay and recovery from Covid-19;

* Vision status and use of glasses;

* Preferred sleeping in a recliner chair; and

* Home Health RN services.

There was no documented evidence the facility had completed a quarterly service plan for the resident, which would have been due on or around 01/08/23.

7. Resident 7 was admitted to the facility in 12/2021 with diagnoses including hypertension and chronic obstructive pulmonary disease.

Observations and interviews with the resident and staff were conducted between 04/10/23 and 04/11/23 and the resident's most recent service plan, dated 09/21/22 was reviewed. The service plan was not reflective and/or did not provide clear direction to staff in the following areas:

* Refusals of showers and preference for taking baths;

* Wheelchair mobility;

* Use of dentures;

* Recent falls and interventions;

* Use of oxygen including, flow rate and instruction if assistance was needed;

* Frequency of hospice visits; and

* Emergency evacuation ability.

There was no documented evidence the facility had completed a quarterly service plan for the resident, which would have been due on or around 12/20/22.

The need to ensure service plans were reviewed and completed quarterly, provided clear directions and were reflective of current needs was discussed with Staff 1 (ED), Staff 2 (RN, Health Services Director) and Staff 3 (RCC) on 04/13/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 03/2023 with diagnoses including dementia and a seizure disorder. The resident was reported as bed bound and receiving Hospice services.

The resident's current service plan, dated 03/22/23, was reviewed, observations were made and interviews with the resident and caregivers were conducted on 04/12/23. Resident 2's service plan did not provide clear instruction to staff in the following areas:

* Eating and "dining" needs; and

* Bathing.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) and Staff 3 (RCC) on 04/13/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly, were reflective of resident needs, provided clear direction regarding delivery of services and were followed for 7 of 7 sampled residents (#s 1, 2, 3, 4, 5, 6 and 7) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 03/2022 with diagnoses including cerebrovascular accident.

Review of the clinical record, observations and interviews with staff and Resident 1 were completed during the survey. Review of the current service plan dated 01/26/23 and subsequent temporary service plans revealed they were not reflective of his/her needs and staff were not following the service plan in the following areas:

* Need for assistance with bladder and bowel incontinent care;

* Need for assistance with dressing; and

* Transfers, including use of a gait belt and encouraging the resident to wear shoes or nonskid socks when transferring.

The need to ensure service plans were reflective and staff followed the service plan was discussed with Staff 1 (ED), Staff 2 (RN, Health Services Director), and Staff 3 (RCC) on 04/13/23. They acknowledged the findings.

1. Health Services and Executive Director will conduct a comprehensive review of all Service Plans to ensure that all Service Plans are updated and current to reflect the resident's needs and personal preferences that support the principles of dignity, privacy, choice, individuality.  The service plans will be checked to ensure that there are clear directions on what the services are and how to complete.  As well as who is responsible for the task, when and how often the task is completed.

2. System to prevent re-occurance: The Executive Director and RCC will create a Service Plan Schedule.

3. RCC and Executive Director will ensure that a new schedule is created by the 15th of every month for the upcoming month.  

Staff members responsible: RCC, Executive Director and Health Service Director

Based on interview and record review, it was determined the facility failed to ensure physician's orders were carried out as prescribed for 2 of 6 sampled residents (#s 3 and 5), whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including renal failure.

Physician's orders and MARs dated 03/01/23 - 04/10/23 were reviewed and revealed the following:

* Medications administered to the resident prior to the hour of sleep (HS) had two options for unlicensed staff to choose from; either 8:00 pm or 10:00 pm. The physician's order directed staff to administer the medications daily at 8:00 pm. Multiple HS medications were administered at 10:00 pm.

* On 03/15/23, Resident was prescribed doxycycline to treat un upper respiratory infection. The physician's order was for the facility to administer one, 100 mg tablet two times a day for 10 days. The facility administered 19 out of the 20 tablets prescribed.

* A physician's order for a daily weight was not carried out as prescribed on 04/07/23.

* There was no documented evidence the resident's levothyroxine (to treat hypothyroidism) was administered on 03/24/23 as it was left blank on the MAR.

* Midodrine (to treat low blood pressure) was not administered on 03/21/23 and 03/23/23.

* Prednisolone eye drops (to treat red eye) was not administered on multiple occasions due to Resident 3 being at dialysis.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN, Health Services Director) on 04/13/23. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 12/2018 with diagnoses including cognitive disorder.

Physician's orders and MARs dated 03/01/23 - 04/10/23 were reviewed and revealed the following:

* Resident 5 had a physician's order for the facility to monitor the resident's behaviors, bowel movements and meal intake. There were multiple blanks on the resident's MARs with no documented information if the orders were carried out as prescribed.  

* A physician's order directed staff to administer Milk of Magnesia, 30 ml "by mouth if no bowel movement in [three] days or for complaint of constipation." There were five instances in 03/2023 in which the facility should have administered the medication.

The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED) and Staff 2 (RN, Health Services Director) on 04/13/23. They acknowledged the findings.

1. Run the "missed meds" report daily.  Discuss any discrepencies with med techs at weekly Med Tech meetings until are discrepencies are fixed.

2. Mandatory Dashboard Sign Off during shift change. This should ensure that all med passes are complete before the next shift takes over.    

3. RCC and Health Service Director will audit the Mandatory Dashboard Sign Off sheet daily and address any discrepencies immediately.  

Responsible Staff: Executive Director, RCC and Health Service Director.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instruction for use for PRN medications for 1 of 6 sampled residents (# 3) whose MARs were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 10/2022 with diagnoses including renal failure.

Physician's orders, MARs dated 03/01/23 - 04/10/23 and progress notes dated 01/13/23 - 04/13/23 were reviewed and revealed the following:  

* The parameter for 800 mgs of sevelamer carbonate (to lower the amount of phosphorus in the blood relating to dialysis) was to administer two to three tablets daily, without clear direction to staff regarding when to administer two versus three tablets.

* There were multiple orders for midrodrine (to treat low blood pressure) both for scheduled and PRN administration. There were no clear instructions regarding frequency of the routine medication and when to administer the PRN dosage.

* The resident went to the hospital and returned to the facility 02/04/23. A progress note dated 02/04/23 directed the facility to discontinue the Milk of Magnesia. The medication was listed on Resident 3's MARs.

On 04/13/23 at 1:27 pm, Staff 2 reported the resident's physician had re-instated the order for Milk of Magnesia. No further documentation was received.

The need to ensure MARs were accurate and contained resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) Staff 2 on 04/13/23. They acknowledged the findings.

Health Services and Executive Director will review all med orders to ensure that appropriate PRN parameters are in place with clear instructions.  The discrepencies found during survey for resident #3 have been fixed.

Health Service Director and RCC will review PRN parameters when signing off on orders.

On-going the PRN parameters will be audited by RCC, HSD, and Executive Director on a weekly basis.   

Based on interview, observation and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications, for 2 of 2 sampled residents (#s 3 and 4) who administered their own medications. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2022 with diagnoses including renal failure.

The service plan indicated Resident 3 administered all of their own medications, however, during an interview with the resident on 04/12/23 at 10:56 am, Resident 3 stated s/he only self administered the "pain and dialysis [medications]." The resident pointed to the prescription bottles to his/her right on a shelf.

The Self-Medication Evaluation was completed by Staff 2 (RN, Health Services Director) on 10/30/22. On 04/13/23 at 1:27 pm, Staff 2 confirmed the Resident 3 had not been evaluated quarterly to assure ability to safely self-administer medications.  

The need to complete evaluations of a resident's ability to self-administer medications at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 04/13/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 10/2022 with diagnoses including chronic pain, nerve pain and insomnia.

The service plan indicated Resident 4 administered all of their own medications, including a morphine pump to treat pain. During an interview with the resident on 04/12/23 at 10:56 am, Resident 4 confirmed s/he "ordered [the medications] and took them on [his/her] own." The resident confirmed not having any issues with his/her medication management system.

The Self-Medication Evaluation was completed by Staff 2 (RN, Health Services Director) on 10/30/22. On 04/13/23 at 1:27 pm, Staff 2 confirmed Resident 4 had not been evaluated quarterly to assure ability to safely self-administer medications.

The need to complete evaluations of a resident's ability to self-administer medications at least quarterly was discussed with Staff 1 (ED) and Staff 2 on 04/13/23. They acknowledged the findings.

HSD will audit all Self-Med orders and ensure self med assessments are current.

Self Med assessments will be done quarterly when the service plans are updated.  

HSD and RCC will audit for any new self med orders and ensure that the HSD has a completed a new self med assessment as needed for any new orders.  

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

Review of facility records on 04/11/23 identified the following deficiencies:

* There was no documented evidence that fire drills were conducted every other month, as required; and

* There was no documented evidence that Fire and Life Safety instruction was provided to staff on alternating months.

On 04/12/23 the need to conduct fire drills every other month and provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (ED), Staff 2 (RN, Health Services Director) and Staff 5 (Environmental Services Director). They acknowledged the findings.

Fire and Life Safety in-services will be provided during all-staff manadory meetings on the alternate months of fire drills.

Fire Drills have been conducted on 4/30/23 and 5/1/23.

Fire and Life Safety in-service will be held at the All-Staff meeting in June 2023 then on-going on alternating months.  

Executive Director will ensure that the Environmental Service Director has a time slot for the All-Staff meetings and that there is an appropriate Fire and Life Safety subject chosen every other month alternating with actual Fire Drills.

Responsible staff: Environmental Services Director and Executive Director

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 04/11/23 identified the following deficiencies:

There was no documented evidence annual training on fire safety was provided to residents.

On 04/12/23 the need to provide and document fire safety instruction to residents, at least annually, in accordance with the OFC was discussed with Staff 1 (ED), Staff 2 (RN, Health Services Director) and Staff 5 (Environmental Services Director). They acknowledged the findings.

1. We have a form that is filled out during the move-in assessment.  The form is Emergency/Disaster Orientation Form.  This is where we explain how the call system works, explain the fire alarm procedure. This is apart of our move-in process.  

3. To ensure that all residents have the information available to them, the Fire Drill Protocol will be discussed at the May Town Hall meeting.  This will be announced prior to the meeting so all residents will know about it and can make the choice of attending.

2. The community will be using a new Fire Drill Log that will incorporate the residents into the Fire Drill Process.  This will ensure that every resident has the opportunity to participate in the fire drills at least yearly, but more often.

Responsible Staff: Environmental Service Director and Executive Director

Based on interview and observation, 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 610 and C 613.

Refer to Plan of Corrections regarding tags C 610,  

C 613, and C 615

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

The facility's exterior grounds were toured with Staff 5 (Environmental Services Director) on 04/11/23. The following issues were identified:

There were drop-offs of up to 3 inches from concrete surfaces to bark dust beds along the edges of multiple walkways and patio surfaces. The drop-offs created a tripping hazard for residents.

The need to ensure all exterior pathways and surfaces were in good condition and free from drop-offs was discussed with Staff 1 (ED) and Staff 5 on 04/12/23. They acknowledged the findings.

Environmental Service Director walked the grounds with the landscaping company on 4/28/2023.  Showed all the "drop-off" spots.  

The landscaping company will begin fixing the drop-offs immediately.  

Environmental Services Director will walk the exterior grounds on a weekly basis to ensure these areas remain fixed and can address any new issues as they arise with the weekly landscaping service.  

Responsible Staff: Environmental Services Director

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were properly labeled and maintained in a locked storage unit, exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents, and facility grounds were kept free of litter and refuse. This is a repeat citation. Findings include, but are not limited to:

The exterior of the facility was toured on 07/26/23. The following were identified:

*Exterior pathways around the perimeter of the building contained multiple drop offs up to approximately 2 inches, measured from the concrete to the ground;

*Multiple cigarette butts as well as general litter and refuse were observed throughout the facility grounds;

*Multiple pesticides were observed unattended to by a side door;

*Multiple bags filled with kitchen rags were observed near a side door;

*Multiple window screens were leaned against the building;

*An unattended circular saw was observed by a side door; and

*Wood with a nail sticking out near a concrete pathway.

On 07/26/23, the building's exterior was toured with Staff 1 (ED) and Staff 5 (Environmental Services Director). They acknowledged the findings.

1.

A)Landscape Company comes out every Friday.  They will be bringing material to fix "drop off" issues starting 8/18/2023.  

B)Environmental Service Director will do morning exterior walks of the community to pick up any trash such as cigarette butts, garbage, ect.  He will look for anything out of place and put where it belongs. Ensure that there are no community tools or gardening tools/materials left unattended.  

2.

A)Environmental Service Director will ensure that all "drop offs" will be fixed by the landscapers no later than 9/10/2023.  The ESD will then maintain and notify landscapers of any new "drop offs" during his daily exterior walk throughs.  Landscaping company bringing material to start the drop offs on 8/18/2023.

B)ESD will continue to do morning exterior walks of the building to ensure that the building is clean and free of garbage, and nothing is out of order.  

3.

The exterior of the building will be walked daily Mon-Fri. The landscapers will fix any new drop off areas weekly.  

4.

The ESD and ED will ensure the corrections are completed and monitored.  

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

The interior of the facility was toured with Staff 5 (Environmental Services Director) on 04/11/23. The following areas needed cleaning or repair:

* Multiple areas where wood hand rails showed scrapes and chipped paint;

* The carpet in resident apartments 129 and 134 had dark stains;

* Several residents' door frames had scrapes or chipped paint; and

* There were several florescent ceiling lights burned out on second floor halls.

The areas needing cleaning or repair were discussed with Staff 1 (ED) and Staff 5 on 04/12/23. They acknowledged the findings.

Environmental Service Director will do daily walk-throughs inspecting ceiling bulbs in all common areas, hallway carpets, apartment door frames, hand rails, etc.  

Environmental Service Director will fix and touch up community hand rails, and apartment door frames, as mentioned in the survey.   

To ensure on-going compliance the ESD, Marketing Director and Executive Director will conduct walk throughs on a daily basis and the ESD will provide touch up on any issues as they arise.  

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. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured on 07/26/23. The following areas needed cleaning or repair:

* Ceiling vents in the dining room had an accumulation of dust;
* A window frame in a 2nd story hallway showed barewood and was in need of repair;

* Carpet in corridor's as well as resident apartment 125 had dark stains; and

* Several door frames and doors had scrapes or chipped paint.

On 07/26/23, the areas needing cleaning or repair were discussed with Staff 1 (ED). She acknowledged the findings.

1.

A) Issue: Window frame in a 2nd story hallway showed barewood and needs repair.

Solution: The window is being repaired by an outside vendor.  The company is scheduled to come out and fix the window sill on August 24th.

B)Issue: Ceiling vents in the dining room have an accumulation of dust.

Solution: Better Air Northwest will be coming out to clean the vents in the dining room.  

C)Issue: Carpet in corridor's as well as resident apartment 125 had dark stains

Solution: Will have 125's apartment cleaned

D)Issue: Several door frames and doors have scrapes or chipped paint.

Solution: ESD will be touching up door frames and areas with chipped paint.  

2.

ESD, MD, ED will do daily walk throughs to ensure that the interior of the building is in good condition and looks good.  

3.

Interior of building will be evaluated on a daily basis by walk throughs provided by ESD, ED and MD.

4.

ED and ESD will do daily walk throughs to ensure building remains in compliance going forward.  

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

On 07/26/23, the facility interior was toured. Two corridor windows and three resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.

On 07/26/23, the lack of a mechanism to prevent accidental falls was discussed with Staff 1 (ED). She acknowledged the findings.

1.

Community installed detachable locks to every 2nd floor window.  These locks allow the window to open, but prevent the window from opening up enough for a person to fall out of the window.

2.

ESD will audit 2nd floor windows monthly to ensure all windows still have the locking mechanism in place.  

3.

ESD will audit all 2nd floor windows monthly

4.

ESD and ED