Print Inspection: JZOL

The findings of the re-licensure survey, conducted 10/04/21 through 10/06/21, 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 for 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 revisit to the re-licensure survey of 10/06/21, conducted 1/12/22 through 1/13/22, 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.

2. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and congestive heart failure.

Observations of the resident on 10/04/21 and 10/05/21, interviews with staff, and review of the resident's current service plan and evaluation dated 09/16/21 were conducted during the survey.

The quarterly evaluation was not reflective in the following areas:

* Current skin conditions;

* Significant weight gain; and

* Compression stockings.

The need to ensure quarterly evaluations were accurate and included documented changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in move-in evaluations and to ensure quarterly evaluations were completed on time and were reflective of the resident's current care needs for 2 of 5 sampled residents (#s 1 and 5) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.

The resident's move-in evaluation, dated 06/07/21, was reviewed during survey. The following required elements were not addressed:

* Physical health status, including a list of current diagnoses, a list of medications and PRN use, and visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

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

* How a person expresses pain or discomfort;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

This plan of correction is not to be construed as an admission of or agreement with the findings and conclusions in the Statement of Deficiencies. This plan of correction is being submitted as required by the regulation. The Administrator will ensure all corrective action in the following Plan of Correction has been completed.

The current initial, quarterly and Change in condition resident evaluation form has been updated on our electronic system with the addition of missing questions, such as how a person copes with change or challenging situations, complex medication details, and the impact of environmental factors. We have added additional details that also connect with the care plan. The current form that requests the past physicians visits, hospitalizations, diagnosis's and medication list will be attached to the initial evaluation a to be addressed when creating the service plan.

Residents 1 through 7 have been reassessed and care plans updated in order to address the missing components. Administrator and Health Services Director will monitor the continuing changes and updates to the assessment forms.

New RN has completed the Role of the RN class 10/14/21 in order to better understand her role.

Resident #1 assessment and care plan have been updated. The initial assessment did include new move in orders that included her medication list and diagnosis along with her previous hospitalizations. We are now keeping those with the initial assessment and current assessment.

Resident # 5 assessment and care plan have been updated. RN is monitoring her skin condition weekly as well as her weight gain.

We are currently going through all residents to use the improved assessment to make sure no details are unaddressed.

Administrator and Health Services Director will monitor the continuing changes to assure compliance weekly.

2. Resident 5 was admitted to the facility in 10/2019 with diagnoses including congestive heart failure and diabetes.

Observations of the resident on 10/04/21 and 10/05/21, interviews with staff, and review of the resident's current service plan, dated 09/14/21, were conducted during the survey.

The service plan was not reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Use of compression stockings;

* Home health nursing services;

* Significant weight gain; and

* Current skin conditions to the left shin, abdominal fold, and under the left chest.

The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/05/21. 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 and provided clear direction to staff for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 10/2018 with diagnoses including osteoarthritis and dementia.

Observations of Resident 3 on 10/05/21, review of clinical records, and interviews with staff indicated Resident 3's current service plan, dated 10/04/21, was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following care areas:

* Use of a motorized wheelchair for mobility;

* Medication administration responsibility; and

* Transfer assistance needs.

The need to ensure service plans were reflective of residents' current care needs and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 10/2018 with diagnoses including heart failure and cognitive impairment. Resident 7's service plan was reviewed and caregiving staff and the resident were interviewed. The service plan, dated 07/16/21, was not reflective of the resident's current status and lacked clear instructions to staff in the following areas:

* Hospice services provided;

* Weight changes;

* Direct feeding assistance needed; and

* Symptoms of anxiety.

On 10/06/21, the need to ensure service plans were reflective of the residents' current care needs and included clear direction to staff was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

4. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.

Resident 1's current service plan, dated 07/01/21 and updated 08/11/21 and 09/01/21, was reviewed, and caregiving staff and the resident were interviewed. The service plan did not provide clear instructions to staff for "monitoring, guidance, and occasional redirection" related to his/her poor memory and judgment.

The need for service plans to include clear direction to staff about the provision of care was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.

The resident's current service plan, updated 09/16/21, was reviewed and caregiving staff and the resident were interviewed.

The service plan was not reflective of Resident 4's current status and/or did not provide clear instructions to staff in the following areas:

* Transfer status;

* Assistance with self-administration of special medications;

* Home health services;

* Hallucinations;

* Obsessive-compulsive behavior;

* Communication difficulty; and

* Poor memory and judgment.

The need to ensure service plans reflect the current care needs of the resident and include clear direction to staff regarding the provision of care was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

C260 Residents #1, #3, #4, #5 and #7 care plans have been updated to reflect the necessary changes to the care/service plans. We currently working on re-assessing all residents with the improved assessment that will assist us in building a better person centered care plan that includes how to better address the resident diagnosis by the caregiver on the electronic POC devices and on the care plan itself. All staff will read and sign the hard copy of the quarterly care plans and will be filed into the charts along with a copy that is readily accessible to all staff.

Resident Care Coordinator is taking several assigned Oregon Care Partners Courses including Service Plans and Service plans for ALF. She will also take the next Role of the RCC class January 25, 2022.

Our new RN has completed the Role of the RN class 10/14/21 and will continue to attend OHCA trainings in order to meet the ongoing needs of the community.

Both Health Services Director and the Administrator will audit assessments and care plans monthly for accuracy in order to offer person center care plans that meets the needs of the residents and give clear instructions for care by staff.

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, weekly progress notes until the condition resolved, and/or the facility failed to refer significant changes of condition to the facility RN for 5 of 5 sampled residents (#s 1, 3, 4, 5 and 7) who had changes of condition. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and congestive heart failure.

A progress note dated 09/14/21 revealed a "yeast type of rash" under the left chest.

There was no documentation of weekly monitoring of the skin condition to resolution.

The need to ensure changes of condition were monitored at least weekly to resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/05/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2018 with diagnoses including osteoarthritis and dementia.

Clinical records were reviewed during survey and indicated the resident experienced the following changes of condition:

* Progress notes stated the resident developed a blood blister on 07/09/21. An RN progress note dated 08/09/21 indicated the blister had resolved. There was no documented evidence the blister was monitored between 07/09/21 and 08/09/21.

* An RN progress note dated 08/09/21 stated the resident developed a right groin rash. There was no documented evidence the rash was monitored from 08/09/21 through 09/02/21.

The need to ensure residents who experienced changes of conditions were monitored at least weekly through condition resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.

3. Resident 7 was admitted to the facility in 10/2018 with a diagnoses including heart disease and cognitive impairment.

Review of  Resident 7's clinical records indicated the resident experienced a change of condition related to an 11.8% weight loss from 06/23/21 to 07/21/21.  

There was no documented evidence the facility identified the significant weight loss, determined what interventions or actions were needed or referred the resident's significant weight loss to the facility RN for further evaluation.

On 10/06/21 the need to ensure changes of conditions were monitored, resident-specific actions and interventions were developed and communicated to staff, and the resident service plan was updated was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

4. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.

Progress notes from 07/18/21 through 10/03/21, weight records dated 06/24/21 through 09/14/21 and the resident's current service plan were reviewed, and staff and the resident were interviewed.

Resident 1's weight records indicated the following:

* 06/24/21 - 116 pounds;

* 07/14/21 - 120 pounds;

* 08/03/21 - 124 pounds; and

* 09/14/21 - 125.5 pounds.

As of 09/14/21 Resident 1 had gained 9.5 pounds, or 8.19% of his/her total body weight, in a three month period. Staff 2 (RN) reported she had not been informed of the resident's weight gain.

There was no documented evidence the resident's weight was being monitored.

The need to monitor changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 2, and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

5. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.

Progress notes dated 07/12/21 through 09/29/21, weight records from 04/02/21 through 09/20/21, and medical provider after visit summaries from 07/13/21, 07/22/21, and 09/14/21 were reviewed, and caregiving staff and the resident were interviewed.

Resident 4 experienced the following changes of condition:

* 09/11/21 - Staff documented the resident was placed on alert "due to losing mobility caused by stiffness and pain" in his/her right arm;

* 09/15/21 - The resident returned to the facility from the ER;

* 09/20/21 - Resident 4 weighed 166 pounds, a loss of 25.6 pounds since 06/02/21, or 13.36% of his/her total body weight. The resident had experienced weight fluctuations from 04/02/21 through 09/20/21; and

* 09/27/21 - Staff documented the resident was on alert for "starting new medication Nitrofurantoin for infection."

There was no documented evidence any of these changes of condition were monitored through resolution.

On 10/06/21 the need to monitor all short-term changes of condition through resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

C270 Change of Condition and monitoring; The facility hired a new RN due to the previous RN having quit with out notice. The new RN has completed the Role of the RN class on 10/14/21.

Residents # 1, 3, 4, 5 and 7 are currently being monitored by the RN weekly, changes have been made to care/service plans. The "wisdom to act" featured is going to utilized on the electronic devices to notify the Administrator, RN and RCC of changes in condition with residents the Administrator, RN and RCC will take the training and implement the use and training to the staff. This feature is able to be used by

This will be monitored by the administrator for effective use as well as audits of weekly monitoring on a regular basis by administrator.

2. Resident 5 was admitted to the facility in October 2019 with diagnoses including diabetes and congestive heart failure.

Weight records and progress notes dated 7/22/21 through 10/4/21 were reviewed and indicated the resident experienced an 8.5 pound unplanned weight gain between  8/19/21 and 9/23/21. The gain of over 6% of total body weight constituted a significant change of condition.

The facility failed to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment.

Observations of the resident on 10/04/21 and 10/05/21 showed the resident eating in the dining room independently. Resident 5 was weighed on 10/5/21 at 135.7 pounds, which was 0.7 pounds higher than the 9/23/21 weight.

The need to ensure an RN assessment was completed and included the required components of documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/5/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the RN performed an assessment, developed interventions based on the condition of the resident, or updated the service plan for 4 of 4 sampled residents (#s 1, 4, 5 and 7) who experienced a significant change of condition. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 10/2018 with a diagnosis of heart failure.

Weight records, dated 6/23/21 through 7/21/21, indicated the resident experienced a 19.3 pound weight loss. This constituted an 11.8% severe weight loss in a month and required an RN assessment. There was no documented evidence a thorough RN assessment was completed, and no interventions were developed or implemented as a result of the RN assessment.

On 10/06/21, the failure to conduct an RN assessment for a significant change of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.

Progress notes from 07/18/21 through 10/03/21, weight records dated 06/24/21 through 09/14/21 and the resident's current service plan were reviewed, and caregiving staff and the resident were interviewed.

a. On 08/10/21 the resident experienced a witnessed fall resulting in a fractured elbow and sacrum. Following the fractures, the resident required more assistance with ADLs than prior to the fall.

There was no documented evidence an RN had completed a significant change of condition assessment when the resident experienced the fractures.

The need to ensure an RN assessed all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC) on 10/06/21. They acknowledged the findings. Staff 1 stated the facility RN had quit prior to the fall and they had not yet hired a replacement on 08/10/21, the date of the resident's fall.

b. Resident 1's weight records indicated the following:

* 06/24/21 - 116 pounds;

* 07/14/21 - 120 pounds;

* 08/03/21 - 124 pounds; and

* 09/14/21 - 125.5 pounds.

As of 09/14/21 Resident 1 had gained 9.5 pounds, or 8.19% of his/her total body weight, in a three month period, which constituted a significant weight gain.

There was no documented evidence a significant change of condition assessment had been completed by the RN.

On 10/05/21 survey requested Staff 2 (RN) to weigh the resident. The RN reported the resident's weight was 119 pounds. This was a loss of 6.5 pounds, or 5.18% of his/her total body weight, in three weeks. Staff 2 stated she had not been informed of the resident's weight changes.

The need for an RN to complete an assessment for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

4. Resident 4 was admitted to the facility in 02/2020 with diagnoses including diabetes with neuropathy and chronic kidney disease.

Progress notes dated 07/12/21 through 09/29/21, weight records from 04/02/21 through 09/20/21, and medical provider after visit summaries from 07/13/21, 07/22/21, and 09/14/21 were reviewed, and staff and the resident were interviewed.

Weight records revealed:

* The resident lost 25.6 pounds between 06/02/21 and 09/20/21, or 13.36% of his/her total body weight. This was a severe weight loss.

* The resident gained 9.5 lbs., or 8.19% of his/her total body weight, in a three month period between 06/24/21 and 09/14/21, which was a significant gain.

There was no documented evidence the RN completed a significant change of condition assessment for either of these weight changes.

During survey Staff 2 (RN) was requested to obtain a current weight for Resident 1. On 10/05/21 she reported the resident weighed 200 pounds. This was a gain of 15.4 pounds, or 8.34% of his/her total body weight, in three weeks. Staff 2 (RN) stated she had not been informed of the resident's weight fluctuations.

The need to ensure an RN assessed all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2 and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

C280 - Significant change in condition - RN assessment.  The facility is prepared to hire a temporary RN should the RN quit that has dedicated hours to fill in as the Role of RN at Waverly Place Assisted Living. Administrator will make sure that the fill in RN has information readily available to monitor changes in conditions.

The current RN has completed the Role of the RN class and understand the duties, we are adding an LPN to assist as Med room manager along with assisting the RN with other duties as assigned by the RN so the RN can effectively perform her duties to maintain compliance.

Resident # 1, 4, 5 and 7 are all being monitored, and each individual need has been addressed with the PCP, Hospice or Home Health care plans and community instructions have been updated.

Administrator will monitor weekly to assure that proper documentation and monitoring is happening throughout the community. Administrator will meet with RN weekly to discuss current change in condition monitoring.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#5) who received insulin injections by unlicensed staff. Findings include, but are not limited to:

Delegation records for Resident 5, reviewed with Staff 2 (RN) on 10/04/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 13 (MA), Staff 16 (MA) and Staff 18 (MA), including:

* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;

* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons; and

* Frequency the client should be reassessed, including rationale.

The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator) and Staff 2 on 10/05/21. They acknowledged the findings.

C282 - Delegation.  The RN now has a better understanding of the Role of the RN she has completed the class on 10/14/21. Since finishing the class RN is in the process of re-delegating all the medication technicians.

The RN used the same forms and process as the previous RN who quit left behind, being new to the role she did not know she did not have the correct information. She has since learned how to properly delegate. Including an assessment of each of the diabetic resident's history to determine if their condition is stable and predictable. Also, a bio & history of med techs she is delegating insulin tasks in order to determine they are safely delegated.

RN will monitor the delegation tasks monthly and resident assessments as required per State of Oregon.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#6) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 6's signed physician orders, dated 08/10/21, included the following orders:

* Oxycodone/APAP Tab 5-325 mg as needed every eight hours for pain.

Review of the Controlled Substance Disposition logs and the resident's 09/01/2021 through 09/30/2021 MAR identified the following:

* A 09/24/21 dose of Oxycodone/APAP at 1:41 pm was reflected in the disposition log but not on the MAR.

On 10/06/21, the need to ensure narcotic disposition logs and MARs were accurate and medications were recorded appropriately was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

C302 - Tracking Controlled Substances - RN and RCC will utilize a weekly med room audit form that includes monitoring of the eldermark MAR system and comparing it to the narc book weekly. All medication technicians being re-assigned the eldermark training regarding the proper use of the electronic MARS.

Administrator will follow this process to maintain compliance with monthly monitoring of audit forms.

3. Resident 3 was admitted to the facility in 10/2018 with diagnoses including dementia.

Resident 3's current physician orders and MARs dated 09/01/21 through 10/04/21 were reviewed and indicated the following:

* Staff documented an order for daily Ativan (a medication for anxiety) was not administered to the resident, because the medication was not available, on four occasions in September.

During an interview on 10/05/21, Staff 2 (RN) and Staff 5 (RCC) stated they investigated the medication error and concluded the staff members (who documented the medication was not available) were not aware where this medication was stored.

The need to ensure medication orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/06/21. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 10/2019.

Current physician orders, the 09/01/21 through 09/30/21 MAR, and the medical record for Resident 5 were reviewed.

Progress notes revealed Resident 5 reported to Staff 2 (RN), on 09/14/21, a new rash under the left chest area.

During an interview on 10/05/21 at 9:05 am, Staff 5 (RCC) reported the rash was being treated twice a day with the same medicated cream used on the resident's lower abdomen rash.

The signed physician orders dated 08/11/21 included Lotrisone cream to be applied twice daily to "underbelly fold" for yeast.

There was no signed order for the Lotrisone cream to be applied to the rash located below the left chest area.

The need to ensure there were physician or other legally recognized practitioner orders specific for all wound care provided was discussed with Staff 1 (Administrator) and Staff 2 on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed and were documented in the resident's facility record for 3 of 5 sampled residents (#s 1, 3 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2021 with diagnoses including atrial fibrillation and anxiety.

The resident's 09/01/21 through 09/30/21 MAR, physician orders, and 07/18/21 through 10/03/21 progress notes were reviewed, and Staff 2 (RN) was interviewed. Resident 1 was prescribed warfarin (a blood thinner) for atrial fibrillation.

Staff 2 documented in a progress note on 09/08/21 the resident had not been administered his/her warfarin since 08/27/21. The note indicates the RN investigated further and discovered an error was made when an 08/12/21 order for warfarin was entered on the MAR. An order from the anticoagulation clinic was obtained on 09/08/21 and the resident received warfarin that day.

There was no documented evidence the facility administered warfarin to the resident as prescribed from 08/28/21 through 09/07/21, a total of 11 days.

The need to follow physician orders as prescribed was discussed with Staff 2 (RN) on 10/04/21, 10/05/21 and 10/06/21 and with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

C303 - Resident # 1 will now go for her INR during the weekday instead of Saturday to avoid delay of receiving her ordered Warfin. She was going in on Saturday mornings and faxes were not being received until Mondays.

A separate tab has been placed into our 24-hour binder for the RN to review and approve that all Warfin orders that have entered match with the MARS. RN will review all changes and confirm that orders are correct and contact the anti-coag clinic with questions.

RN and RCC will monitor this daily. Staff are being trained on the new process; 1.) receipt of Warfin order 2.) MT fax order to Pharmacy 3.) MT place order in the tab behind WARFIN ORDERS 4.) MT check pending review from pharmacy against the order for accuracy. 5.) RN to check the order and MAR for accuracy.

Resident # 5 Order was requested from PCP that states exact place the medicated cream can be used. We created a special fax form for PCP's to clarify the correct placement of creams and the use of them for community instructions.

New RN understands that creams must be specific to the area to be applied. We have faxed all resident PCP's for clear instruction for creams and patches. RN will monitor progress and update community instruction in the MAR.

Weekly MAR to Cart audit to make sure all medications are assessable by MT will be completed by RCC. To ensure medications are placed in the proper section of the cart. RN will monitor the audit to make sure that medication orders are carried out as prescribed.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included clear instructions for 2 of 5 sampled residents (#s 1 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 10/2019 with diagnoses including diabetes and received daily insulin injections by unlicensed staff.

Review of Resident 5's 09/01/21 through 09/30/21 MAR revealed the resident had orders to check CBGs (blood glucose levels) before breakfast and in the evening daily.  The MAR lacked clear instruction to staff on when to notify the physician and/or RN of abnormal CBGs or when to hold the insulin for low CBGs.

The need to ensure there were clear instructions on the MAR about when to notify the physician and/or RN of abnormal CBGs and when to hold the insulin for low CBGs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2021 with diagnoses including osteoarthritis.

Review of the resident's 09/01/21 through 09/30/21 MAR identified multiple blanks where staff had not initialed for administration of Hydrocodone/APAP.

On 10/06/21 the need to ensure accurate MARs was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

C310 - Medication administration. All diabetic resident's PCP's have been faxed to clarify when the physician should be notified of abnormal blood sugars.

RN has added the instructions to each diabetic residents MARS in the facility.

In the event of new diabetics, we will get instructions for abnormal CBG readings and when to hold the insulin for low CBGs. RN will monitor all diabetic MARS to make sure the MAR is updated and accurate.

MT training scheduled to train on the importance of initialing the MARS and writing and explanation as to why a medication is help. 1.) If a medication is held or unavailable, they must still initial and write a note as to why. Including notifying the RCC and RN, and a fax to the PCP along with a chart note.

Pro-Pac pharmacy to monitor the MARS quarterly and report to RN and Administrator.

2. Resident 2 was admitted to the facility in 11/2018 with diagnoses including anxiety.

Review of the resident's 09/1/21 through 09/30/21 MAR showed the following psychotropic medication:

* Clonazepam 0.5 mg (a psychotropic medication), one tablet a day as needed for anxiety.

The facility administered the Clonazepam to the resident on 14 occasions between 09/1/21 and 09/21/21. The medication was discontinued on 09/22/21.

The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety. Additionally, there was no documentation of what non-drug interventions were attempted and ineffective prior to administration of the medications.

The need to ensure there were resident-specific descriptions of how the resident expressed anxiety and that non-drug interventions were attempted and documented as ineffective prior to administration of the medication was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 10/05/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had  resident-specific parameters and non-drug interventions were attempted prior to administering the medication for 2 of 2 sampled residents (#s 2 and 7) who were prescribed PRN medication to address behaviors. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 10/2018 with diagnoses including anxiety.

Review of the resident's 09/1/21 through 09/30/21 MAR showed the following psychotropic medications:

* Haloperidol 5 mg (a psychotropic medication), one tablet every 6 hours as needed for anxiety.

* Lorazepam 0.5 mg (a psychotropic medication), one tablet every 4 hours as needed for anxiety.

The MAR did not contain resident-specific parameters for staff describing how the resident expressed anxiety.

On 10/06/21, the need to ensure there were resident-specific descriptions of how the resident expressed anxiety was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 5 (RCC). They acknowledged the findings.

C 330 Resident # 2 and Resident # 7 have parameters added to the MAR. Both residents have had descriptions of how the residents express anxiety in both the care plan and MARS. non-drug interventions have been added to both residents.

A chart audit has been requested from pro-pac to assist with adding parameters to all residents who take anti-psychotic PRN medications. Once audit is complete non-drug interventions resident specific will be added to each chart. RN will oversee that all new prescriptions for anti-psychotics will have resident specific interventions as they are ordered by PCP. RN will monitor the interventions to see if they are working on a monthly basis and participate in the care plan meetings so that we have the proper interventions documented.  

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff (#16) completed all required pre-service orientation prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed on 10/05/21.

There was no documented evidence Staff 16 (CG), hired 8/30/21, had completed the following pre-service orientation topics:

* Resident rights and values of community based care;

* Abuse reporting requirements; and

* Standard precautions for infection control.

The need to ensure documentation of completed pre-service training was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

C370 Pre-service training - Staff #16 has completed the resident rights, abuse reporting and standard pre-cautions for infection control.

We have ended our contract with Relias due to not being assigned the proper training modules for compliance. We have printed the class list from Oregon Care Partners and have created a new hire online training checklist along with other trainings we require. We are also re-building our record keeping binder by month/date hire so we have the appropriate trainings annually.

Administrator will oversee the training and the record keeping to maintain compliance as new staff are hired and monthly.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long term staff (#s 9, 12 and 14) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 10/05/21 and revealed the lack of documented evidence Staff 9 (CG), Staff 12 (CG) and Staff 14 (MA), hired 06/04/19, 09/30/21, and 06/21/19, respectively, completed one of the following:

* A minimum of six hours of training annually related to the provision of care; and

* A minimum of six hours of training annually related to dementia care.

The need to ensure all required in-service training hours and requirements were completed and documented annually was reviewed with Staff 1 (Administrator) and Staff 5 (RCC) on 10/06/21. They acknowledged the findings.

C374 Staff # 9, #12 and #14 are currently working on staff training for compliance.

We have ended our contract with Relias due to not being assigned the proper training modules for compliance. We have printed the class list from Oregon Care Partners and have created a new hire online training checklist along with other trainings we require. We are also re-building our record keeping binder by month/date hire so we have the appropriate trainings annually.

Administrator will oversee the training and the record keeping monthly to maintain compliance.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire and life safety records for 07/2021 through 09/2021 were reviewed with Staff 4 (Maintenance) on 10/05/21. Staff 4 reported the facility was not evacuating or relocating residents during fire drills; therefore, the facility's fire drill documentation did not include the following elements:

* Escape route used; and

* Number of occupants evacuated.

The need to ensure the facility documented all required components was discussed with Staff 4 (Maintenance) and Staff 1 (Administrator) on 10/05/21. They acknowledged the findings.

C420 - Fire Drills - In order to be in compliance, we are;

1.)Three normal fire drills week one.

2.)Week two three practice runs of the evacuation route.

3.)Week three and every week after 2 drills per week until December.

4.)Starting December 1, 1 drill with evacuation per week.

5.)Beginning January 1, 2 drills with evacuation per month.

Documented drills will be on every shift. This will be monitored monthly by the administrator.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were conducted according to the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Fire and life safety records were reviewed with Staff 4 (Maintenance) on 10/05/21. The facility lacked documented evidence of the following:

* Alternate exit routes were used during fire drills; and

* Annual fire and life safety training for residents; including all required training topics.

Multiple staff interviewed on 10/05/21 were unaware of the designated point of safety.

The need to ensure all fire drills were conducted in accordance to the OFC, was discussed with Staff 1 (Administrator) and Staff 4 on 10/05/21. They acknowledged the findings.

C422 - Fire and Life Safety

Weekly meetings 1:1 with each current resident will be conducted to go over safety training, fire and other natural disasters. Meetings will consist of general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors.

Upon new move in within 24 hours safety training will be dome with the resident that covers safety training, fire and other natural disasters, general safety procedures, evacuation methods, responsibilities during fire drills, where the designated meeting place is outdoors along with responding to questions the residents may have.

Each resident will receive printed instructions for future reference, each training will be documented and kept in the resident file and in a resident training binder by room number.

Administrator, Director of maintenance and other designated staff will provide training. Administrator will maintain all training records and monitor monthly.