Print Inspection: K39Y

The findings of the re-licensure survey conducted 9/13/21 through 9/15/21 are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit survey to the re-licensure survey of 09/15/21, conducted 01/31/22 through 02/02/22, 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 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 second re-visit to the re-licensure survey of 09/15/21, conducted on 04/19/22 through 04/20/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare for 1 of 1 sampled resident (#6) reviewed for infection control and ADL incontinent care. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2015 and admitted to Hospice in August 2021.

Observations and interviews with staff and family members revealed Resident 6 was incontinent of bladder and relied on staff for all incontinence care needs.

On 9/15/21 at 12:08 pm, the surveyor obtained permission to observe two person ADL incontinent care for Resident 6. During the observation, Staff 10 (Resident Assistant) failed to change gloves after removing a soiled incontinent product and wiping urine from Resident 6's perineum. Staff 10 removed a soiled mattress cover from the resident's bed and handed it to Staff 12 (Resident Assistant). Staff 12 placed the soiled mattress cover and soiled blanket directly on the carpet flooring and failed to don clean gloves before assisting the resident to roll to the left side. Staff 10 proceeded to touch the resident's clean incontinent brief, closet door, the resident's clean mattress cover, clean bed linens, and fall mat while wearing the same soiled gloves. After care was completed, neither staff was observed performing hand hygiene after glove removal. Staff 12 donned clean gloves and proceeded to pick up the soiled linens off the floor and place them in a clear trash bag. Staff 10 proceeded to handle soiled incontinent products in a clear trash bag with bare hands.

The above observations and the need to ensure staff consistently used universal precaution was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Staff #10 will be trained on proper hand hygiene, infection control and glove use.

Staff # 12 will be trained on proper procedure for soiled linens using standard precautions and hand hygiene, infection control and glove use.

Education and training with all staff on standard precaution and infection control. Education includes these components: standard precautions, infection control, hand hygien, soiled linens and proper glove use.

2. Revise New-Hire and Annual Competency Evaluations to include hand hygiene and proper glove use.

3. Audit will be completed quarterly by the Resident Services Coordinator to ensure Competency Evaluations are done per policy.

4. Administrator.

Based on observation and interview, it was determined the facility failed to ensure all residents were treated with dignity and respect and failed to ensure residents received services in a manner that protected privacy for 1 of 1 sampled resident (#6) during ADL care. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 2015.

During the acuity interview on 9/13/21, Staff 1 (Administrator) noted the resident was dependent on staff for all ADL care and was recently admitted to Hospice and was bedbound.

The surveyor obtained permission to observe ADL incontinent care on 9/15/21 at 12:08 pm. Staff 10 (Resident Assistant) and Staff 12 (Resident Assistant) provided incontinent care and proceeded to change the resident's bedding. The residents preference was to not wear clothing and would often times only wear an incontinent brief and blanket covering his/her body. During incontinent care and while the bedding was changed, the two Resident Assistant's removed the blanket leaving the resident's upper body exposed.

The above observations and the need to ensure residents were treated with dignity, respect and privacy when incontinent care was provided was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Resident # 6 will have a TSP initiated that instructs staff on proper way to provide care while keeping privacy standards.

Education with current staff will be completed on Resident Rights with an emphasis on privacy, and dignity and respect.

2. Revision of Competency Evaluations to include Dignity and Respect evaluations upon hire and annually.

3. Audit will be completed quarterly by the Resident Services Coodinator to ensure Competency Evaluations are done per policy.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure a thorough investigation was completed, which documented abuse/neglect was ruled out or the incident was reported to the local SPD office if abuse could not reasonably be ruled out for 2 of 2 sampled residents (#s 2 and 6) who had documented unwitnessed falls and an injury of unknown cause. Findings include, but are limited to:

1. Resident 2 was admitted to the facility October 2020, with diagnoses including unsteady gait, hypertension, diabetes, and endothelial corneal dystrophy (a disease of the eye).

Clinical records were reviewed during survey and indicated the following:

a. Resident 2's service plan dated 7/12/21, indicated the resident was alert and oriented to self, time and place but did display mild impairments and confusion when making decisions. The resident used a walker to assist with ambulation and was independent for transfers. The resident required staff assistance with dressing twice per day. The resident had a history of falls and staff were to provide risk monitoring checks once a shift.

An incident report dated 7/30/21, stated staff responded to the resident's call light and found the resident on floor in his/her apartment. The resident stated s/he fell when reaching for his/her walker after getting up from a recliner chair. EMS (emergency medical services) were called and the EMTs (emergency medical tech) determined the resident did not need further evaluation at the hospital. The resident had complaints of immobility and pain on the morning of 8/1/21 but initially refused to go to the hospital. The resident's family took him/her to the hospital later in the afternoon and the resident returned to the facility that evening with a diagnosis of pelvic fracture.

There was no documented evidence the incident was reported to the local SPD office and the post incident investigation dated 8/6/21, did not provide information related to how the facility ruled out abuse. Additionally, the report provided conflicting information related to the resident's diagnosis of hypertension, diabetes and vision loss.

b. Resident 2's service plan dated 8/17/21, indicated the resident preferred to "remain in bed and not move around" related to pain from a pelvic fracture. Staff were to provide risk monitoring checks, incontinence care and repositioning four times per shift.

An incident report dated 9/11/21, stated the resident's family member found the resident on the floor in his/her apartment. The family member called for staff assistance; no injury was noted. The resident stated s/he tripped when walking out of the bathroom.

There was no documented evidence the incident was reported to the local SPD office and there no was no documented evidence the facility completed a thorough investigation to determine whether staff had provided repositioning, incontinence checks and monitoring checks as directed per the service plan prior to the incident to rule out potential neglect.

The need to ensure a thorough investigation was completed for all incidents/accidents involving residents and/or report the incident to the local SPD office if abuse could not reasonably be ruled out was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings. The facility reported the incidents to the local SPD office per the survey team request. The facility provided documented confirmation of the report on 9/15/21.

2. Resident 6 was admitted to the facility in 2015.

Clinical records were reviewed during survey and indicated the following:

Charting notes dated 8/2/21 identified the Resident had extensive bruising to the back of his/her left hand and a skin tear just below the inner left elbow.

A review of the service plan dated 5/27/21 indicated the resident had poor short-term memory and confusion related to time and place.

The bruising and skin tear to left elbow constituted an injury of unknown cause.

* On 8/5/21 the RN completed a skin assessment of the injury.

* On 9/3/21 the RN wrote a chart note stating the left hand bruising and skin tear had healed.  

In an interview with Staff 1 (Administrator) on 9/14/21, she was unaware of the injury on 8/2/21 and confirmed the facility should have completed an investigation at the time the bruising and skin tear were identified.  

There was no documented evidence the facility completed an investigation of the incident to rule out suspected abuse or neglect and there was no evidence the facility reported the injury of unknown cause as suspected abuse or neglect to the local SPD office.

The need to ensure injuries of unknown cause were immediately investigated and reported to the local SPD office if abuse could not reasonably be ruled out was discussed with Staff 1 and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Invesigation that states status on whether abuse and neglect had been identified will be completed on both Resident #2 and #6.

Reimplement clinical meeting. Incident reports and investigations will be reviewed daily.

Management team will review regulatory statutes on reporting requirements to be compliant with mandatory reporting.

2. Mangement schedule to identify mandatory reporter for daily coverage.

3. Once a week will audit Incident Report investigation and reporting requirements.

4. Administrator.

3. Resident 1 was admitted to the facility August 2021 with a diagnosis including back strain.

The resident's move-in evaluation dated 7/30/21, did not include the following required information:

* Use of assistive devices (bed side rails and trapeze bar for mobility); and

* Interests, hobbies, and social/leisure activities.

The need to ensure the move-in evaluation included all required information was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an initial new move-in evaluations included information on all required elements for 2 of 2 residents (#s 1 and 5) and failed to ensure quarterly evaluations were completed timely and were reflective of the residents' current status for 1 of 6 sampled resident (#6) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in July 2021 with diagnoses including chronic lower back pain and sciatica. During the acuity interview on 9/13/21, Resident 5 was identified as a fall risk.

Resident 5's initial move-in evaluation completed 7/1/21, lacked the following required elements:

* Pain including pharmaceutical and non-pharmaceutical interventions and how a person expresses pain or discomfort; and

* Risk indicators including fall risk and history.

The need to ensure new move in evaluations addressed all required elements to develop an initial service plan was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

2. Resident 6's clinical records were reviewed during survey and identified the following deficiencies:

a. Resident 6's quarterly evaluation was due in August 2021. A copy of the most current evaluation was completed on 9/9/2021.

In an interview, 9/13/21, Staff 3 (Health Services Assistant) confirmed the evaluation should have been completed in August 2021.

b. Resident 6's quarterly evaluation, completed 9/9/21, was not reflective of the resident's current status in the following areas:

* How a person copes with change and challenging situations;

* PRN psychotropic medications;

* Use of hearing aids;

* Scheduled incontinent care;

* Edema;

* Sleep habits;

* Side rails;

* Meal assistance; and

* Environmental factors including room temperature.

The need to ensure quarterly evaluations were completed timely, were accurate and included documented changes of condition was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Resident's (#1, #5, and #6) evaluations will be updated to reflect current status.

2. The evaluation form includes all of the required elements. Staff will be trained on the need to collect all information prior to move-in and updated on reevaluations.

All resident evaluations will be reviewed and updated as needed.

Reimplement Quality Assurance Program to ensure process is in place and utilized.

3. Quality Assurance Program includes monthly audit. The Administrator or designee will provide quality assurance oversight monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to complete quarterly evaluations for 3 of 3 sampled residents (#s 9, 10 and 11). This is a repeat citation. Findings include, but are not limited to:

Resident 9, 10, and 11's quarterly evaluations were reviewed during survey. There was no documented evidence the evaluations had been updated quarterly.

The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

1. Resident's evaluations will be updated to reflect current status/service plan.

2. The evaluation form includes all of the required elements. Staff will be trained on the need to collect all information prior to move in and updated on reevaluations.

All resident evaluations will be reviewed and updated as needed.

3. LPN will conduct quarterly evaluations and submit to RN for review and approval. RN will conduct quarterly evaluations on residents with increased nursing needs.

4. Reimplement Quality Assurance Program to ensure process is in place and utilized. Quality Assurance includes chart audit. The Administrator or designee will provide quality assurance oversight monthly.

5. RN, Administrator

3. Resident 1 was admitted to the facility August 2021.

Review of the resident's current service plan and temporary service plans revealed the service plans were not reflective of the residents use of bed side rails and trapeze bar to aid in mobility.

The mobility devices were observed in place on the resident's bed on 9/14/21 and the resident stated the devices were used to help him/her get out of or move around in bed.

The need to ensure the service plan was reflective of the resident current status and care needs was discussed with Staff 1 (Administrator) and Staff 2 (Director of Health Services/RN) and Staff 4 (Director of Nursing Services) on 9/14/21. 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' needs, updated during changes of condition and provided clear caregiving instructions for 3 of 6 sampled residents (#s 1, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in July 2021 with diagnoses of chronic lower back pain and sciatica.

Observations of resident ADL care, on 9/13/21 through 9/15/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey. The service plan dated 7/2/21 was not reflective of the resident's status and failed to provide clear caregiving instructions to staff in the following areas:

* Pain management; and

* Activities, social and leisure.

2. Resident 6 was admitted to the facility in August 2015. During the acuity interview on 9/13/21 the Resident was identified as needing full ADL assistance and had recently been admitted to hospice.

Observations of resident ADL care, 9/13/21 through 9/15/21, interviews with staff and review of the resident's current service plan dated 9/14/21 and temporary service plans were conducted during the survey. The service plan was not reflective of the resident's current care needs and/or failed to provide clear instructions for the delivery of care and services in the following areas:

* Frequency and responsibilities of hospice services, including Chaplain services;

* Need for repositioning and assistance with bed mobility;

* Two-person incontinence care;

* Instructions for staff to provide incontinent care in bed;

* Use of hearing aids;

* PRN oxygen;

* Need for PRN laundry services due to incontinent care; and

* Environmental factors including room temperature.

The need to ensure service plans were reflective of the residents' current status and care needs and provided clear instructions for staff was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Resident's( #1, #5, and #6) Service Plans will be updated to be reflective of current health status, with clear direction to staff in regards to specific needs including: pain management, activities, hospice services, repositioning, two person assist, incontinence care, hearing aids, oxygen use, repositioning assist, laundry and environmental factors.

Complete an assistive device with restraining qualities assessment for Resident #1. Include specific devices on the service plan and how the resident uses them.

2. All service plans will be reviewed and updated as needed.

Reimplement Quality Assurance Program to ensure process is in place and utilized.

RA worksheets will be updated weekly with appropriate changes.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed quarterly for 3 of 3 sampled residents (#s 9, 10 and 11).  This is a repeat citation.  Findings include, but are not limited to:

Resident 9, 10 and 11's quarterly service plans were reviewed during survey. There was no documented evidence the service plans had been updated quarterly.

The need to ensure quarterly evaluations were completed in a timely manner was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

1. Residents service plan ( #9, 10, and 11) will be updated to be reflective of current health status with clear direction to staff in regards to specific needs. The facility must incorporate all elements identified in the person - centered service plan into the residents' service plan.

2. All service plans will be reviewed and updated as needed.

3. All service plans will be reviewed by RN prior to implementation in order to ensure critical health status elements are identified, interventions established, and clear direction to staff is part of the record.

Reimplement Quality Assurance Program to ensure process is in place and utilized.

4. Quality Assurance audits will be comlpleted monthly.

5. RN, Administrator  

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution for 2 of 5 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility August 2021 with a diagnosis including hypertension.

Clinical records reviewed during survey (including progress notes dated 8/24/21 - 9/13/21, current service plan, temporary service plans, hospital records, and resident evaluations and assessments) indicated the following:

Resident 1's service plan indicated s/he was alert and oriented to self, place and time, was able to make to make decisions, communicate needs and was independent for managing his/her own medications.

On 9/2/21, progress notes sated the RN evaluated the resident related to complaints of blurry vision. The resident verbalized concerns related to a history of stroke.

On 9/6/21, the resident requested to be sent to the hospital because s/he was concerned s/he was having a stroke because of blurry vision. The resident was admitted to the hospital for observation of possible TIA (transient ischemic attack). The resident returned to the facility on 9/10/21 with a cardiac event monitor and instructions to follow up with cardiology in six weeks.

There was no documented evidence the facility developed interventions and monitored the residents status when s/he complained of blurry vision on 9/2/21.

The facility's change of condition policy was reviewed on 9/15/21. The policy stated when residents experienced short term changes of condition staff would provide appropriate care and initiate alert charting and a temporary service plan.

During an interview on 9/14/21, Staff 2 (Director of Health Services/RN) stated she did evaluate the resident's immediate health status and provided appropriate care on 9/2/21, but she was not aware of the procedure for developing temporary service plans and monitoring.

The need to ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.

2. Resident 2 was admitted to the facility October 2020 with diagnoses including unsteady gait, hypertension, and diabetes.

Clinical records were reviewed during survey and indicated the following.

a. Resident 2 was admitted to hospice services 8/16/21.

In a progress note, dated 8/25/21, staff documented "no hunger and very poor intake". Review of the resident's weight records dated 7/2/21 - 9/14/21, indicated the resident lost 5.8 pounds (4.6% loss in total body weight) from 7/2/21 to 9/7/21. The resident declined to be weighed at the time of survey.

There was no documented evidence the resident's poor appetite and weight loss was evaluated and interventions were determined, documented, communicated to staff, and monitored weekly.

b. Resident 2's current service plan dated 8/17/21 and temporary service plans stated the resident "preferred to stay in bed and not move around" related to pain from a recent pelvic fracture. Staff were to provide incontinence checks and position changes in bed four times per shift.

Progress notes dated 8/23/21 - 9/11/21 stated the resident was able to transfer out of the bed and go to the bathroom with staff assistance.

There was no documented evidence the resident's change in transfer and positioning preferences was evaluated and interventions were determined, documented, communicated to staff, and monitored weekly.

The need to ensure ensure short-term changes of condition were evaluated and interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 2 (Director of Health Services/RN), Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.

1. Resident #1 and #2 will update Service Plan to reflect current needs.

2. Educate Staff #2 on change of condition policy with an emphasis on TSP development and monitoring.

Educate all staff on definition of change of condition with an emphasis on communication to health service's team.

Orientation process includes change of condition education with an emphasis on communication.

Reimplement the weekly issue monitoring log and policy.

3. Quality Assurance audits will be completed monthly. The Administrator or designee will provide quality assurance oversight monthly.

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure resident changes of condition were monitored at least weekly through resolution for 1 of 3 sampled residents (#9) who experienced changes of condition. Resident 9 had a wound that was not monitored weekly, which then worsened over time. This is a repeat citation. Findings include but are not limited to:

Resident 9 was admitted to the facility in 06/2021, with diagnoses including diabetes.

Interviews with staff and review of Resident 9's records, including progress notes dated 11/15/21 through 01/31/22, the current service plan, and current evaluations, indicated the following:

During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) stated Resident 9's spouse lived in the facility and administered all medications and provided all treatments for Resident 9.

On 02/02/22, Staff 6 (MT) stated Resident 9's spouse was usually able to administer all medications and provide all treatments for Resident 9, but may have temporarily had difficulty with those tasks when s/he experienced an illness in the first weeks of 01/2022. Staff 6 stated the spouse was now back to baseline and there were no current concerns related to him/her completing those tasks for the resident.

Progress notes, dated 11/15/21 through 01/31/22, indicated the facility was monitoring a wound on Resident 9's right heel. An RN note dated 12/28/21 noted the wound measured 2 cm by 6 cm and "the open skin is getting slowly smaller." There was no documented evidence the facility monitored the wound after 12/28/21. Staff 19 (Resident Services Coordinator/LPN) evaluated the wound on 02/01/22 per the survey team's request and noted the wound was open, with red and yellow drainage and measured 6 cm by 8 cm.

Resident 9 had a wound on the right heel that was not monitored between 12/28/22 and 02/01/22, the wound progressed and increased in size.

The need to ensure resident changes of condition were monitored weekly through condition resolution was discussed with Staff 1 (Administrator), Staff 18 (Assistant Administrator), and Staff 19 on 02/02/22. Staff acknowledged the findings. They consulted with the facility RN and developed a new treatment plan for Resident 9.

1. Resident (#9) service plan and monitoring will be updated to reflect current skin needs.

2. Clinical staff will be trained on weekly monitoring and conduct clinical meetings daily.

Reimplement the weekly issue monitoring log and policy.

3. RN will review documentation weekly and provide coaching notes, assesments and interventions as needed.

4. Quality Assurance audits will be completed monthly.

The Administrator or designee will provide quality assurance oversight monthly.

5. RN, LPN and Administrator  

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for 1 of 1 sampled resident (#6). Findings include, but are not limited to:

During the acuity interview on 9/13/21, Staff 1 (Administrator) noted Resident 6 required assistance with medication administration and was recently admitted to hospice.

A review of Resident 6's clinical record identified the following deficiencies:

A hospice physician order for PRN oxygen was prescribed on 8/15/21. The order was not transcribed on the September 2021 MAR.

On 9/14/21, observation of the resident's apartment identified there was no oxygen readily available for the resident to use.

In an interview on 9/14/21, Staff 2 (Director of Health Services/RN) was unaware of the order for oxygen and reported the resident doesn't use oxygen. Staff 2 stated they don't have oxygen available for the resident and that she would need to call hospice to clarify the order.

The need to ensure adequate professional oversight of the medication system was discussed with Staff 1 and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. Audit of Resident #6's EMAR to physician orders with corrections as needed.

2. Reimplementation of order review process which includes clearing flags and signing orders in acknowledgement.

3. Physician Orders reviewed and signed quarterly with nurse signature.

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure all written, signed orders for medications and treatments from a legally recognized practitioner were documented in resident records and carried out as prescribed for 2 of 6 sampled residents (#s 3 and 4) whose records were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2014 with diagnoses including quadriplegia. Review of Resident 3's physician orders and MAR, dated 9/1/21 to 9/13/21 identified the following deficiencies:

* The record lacked physician orders for administration of  PRN oxycodone 5 mg and wound care to buttocks;

* Resident 3 was prescribed PRN Norco (for pain) with instructions the facility first offer the resident Tylenol or ibuprofen and document refusals of these, prior to Norco administration. The MAR indicated the resident was administered PRN Norco on 9/1/21, 9/2/21, 9/4/21 and 9/6/21 with no documented evidence that Tylenol or ibuprofen were offered and refused first;

* Records showed cephalexin 250 mg (antibiotic) was not administered as ordered from 9/5/21 to 9/13/21; and

* There was no documented evidence the physician was notified as ordered, following a monthly blood pressure reading outside the ordered parameters on 9/2/21.

2. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes  and hypertension. Review of Resident 4's MAR, dated 9/1/21 to 9/13/21 and physician orders identified the following deficiencies:

* There was no documented evidence the physician was notified as ordered, following a monthly blood pressure reading outside the ordered parameters on 9/1/21.

On 9/15/21 the need to ensure all written, signed orders from a legally recognized practitioner were documented in resident records and carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services).  They acknowledged the findings.

1. Pharmacy audit of orders to medications/treatments beginning with Resident # 3 & 4. The pharmacy will provide list of items that need correction and facility to review and correct.

Health Services staff will be trained on reviewing and implementing orders procedure with an emphasis on parameters, physician notification and order of administration.

2. Will reimplement "Receiving Orders" procedure with Health Services staff and Med Techs.

Will reimplement "Medication Availability" procedure which gives instructions on how to manage medications if they are not in stock.

A third check order processing system will be put in place.

Exceptions and variances will be reviewed in clinical meeting.

3. Issue monitored during clinical meeting. Quality Assurance audits will be completed monthly.

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to orders, for 1 of 1 sampled resident (#3) who had documented medication or treatment refusals.  Findings include, but are not limited to:

Resident 3 was admitted to the facility in 2014 with diagnoses including quadriplegia. Review of Resident 3's MAR, dated 9/1/21 to 9/13/21 identified the following refusals, as documented by staff:

* Fiber Nat powder (for bowel care) was refused on 9/3/21, 9/4/21, 9/5/21 and 9/12/21; and

* Ketoconazole 2% shampoo was refused on 9/3/21 and 9/10/21.

There was no documented evidence the facility notified the physician when the resident refused consent to the orders.

On 9/15/21 the need to notify the physician following a resident's refusal to consent to orders was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services).  They acknowledged the findings.  No further information was provided.

1. Resident #3 physician has been notified of resident's medication refusals identified in SOD.

2. Health Services staff and Medication Technicians will be educated on process for notifying physician of all medication/treatment order refusals.

3. Refusals will be reviewed at least 3 times weekly during the clinical meetings and verification of physician notification will occur.

4. RN and Administrator.

2. Resident 2 was admitted to the facility October 2020 with a diagnosis including Type II diabetes.

Review of Resident 2's MAR, dated 9/1/21 to 9/13/21 identified the following inaccuracies:

* The MAR lacked parameters for daily CBG (capillary blood glucose) checks related to when staff should notify the RN or physician; and

* The MAR did not include a reason for use for the medication glimepiride 1 mg.

On 9/15/21, the need to ensure the facility maintained an accurate MAR was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept of all medications, including over-the-counter medications that were ordered by a legally recognized prescriber and administered by the facility for 3 of 5 sampled residents (#s 2, 3 and 5) whose records were reviewed.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2014.  Review of Resident 3's MAR, dated 9/1/21 to 9/13/21 identified the following inaccuracies:

* The MAR lacked parameters for use for the following PRN bowel medications:  docusate sodium 100 mg, lactulose 10 gm/15mL, and Milk of Magnesia 473 mL;

* The MAR lacked parameters for use for the following PRN cough medications:  guaifenesin 100 mg/5mL and benzonatate 100 mg; and

* The MAR listed the reason for use of Mucinex ER 600 mg as "constipation".  The correct reason for use was congestion.

On 9/15/21 the need to ensure an accurate MAR was kept of all medications ordered by a legally recognized prescriber and administered by the facility was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services). They acknowledged the findings.

3. Resident 5 was admitted to the facility in July 2021 with diagnoses of chronic lower back pain and sciatica.

Review of Resident 5's MAR dated 9/1/21 through 9/13/21 identified the following inaccuracies:

The MAR lacked parameters for use for the following PRN pain medications:  

* Acetaminophen (Tylenol) 650 mg;

* Acetaminophen 325 mg given every four hours; and

* Tramadol.

On 9/15/21 the need to ensure multiple PRN medications prescribed for the same reason had parameters instructing staff on which medication to administer first was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services).  They acknowledged the findings.

1. Audit of PRN medications completed on Resident #2 & 3. Clear, resident specific PRN parameters placed for multiple medication types with an order for each use.

Resident #3, mucinex order use was changed from constipation to congestion.

Resident #2, CBG parameters added to EMAR for notification to physician. Diagnosis added fro glimerpiride.

2. Education will be completed with all Health Services staff on PRN parameters.

When a new Resident Services Coordinator is hired, they will be trained on PRN parameters and process.

All PRN parameters and notification parameters will be reviewed and updated.

Review of PRN and notification parameters during the 3rd check order review process and clinical meeting.

3. Quality Assurance audits will be completed monthly.

4. RN and Administrator.

2. Resident 1 was admitted to the facility August 2021 with a physician order stating the resident was able to self-administer medications.

During an interview with Resident 1 on 9/14/21, s/he reported s/he did self-administer all of his/her medications.

There was no documented evidence the facility evaluated the resident's ability to safely self -administer medications upon move-in.

The need to ensure residents who self-administer medications were evaluated upon move-in was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/14/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to obtain a written physician's order of approval for self-administration of prescribed medications or failed to ensure residents who chose to self-administer their medications were evaluated at move-in and at least quarterly for ability to safely administer their own medications, for 2 of 2 sampled residents (#s 1 and 4) who administered their own medications.  Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 2018 with diagnoses including diabetes and chronic back pain.  Review of the resident's MAR, dated 9/1/21 to 9/13/21 and Self-Administration of Medication Evaluation, dated 6/30/21 identified the following deficiencies:

Records showed the facility failed to evaluate Resident 4's ability to safely administer the following five medications that were self-administered by Resident 4: docusate sodium(for bowel care), GNP Calcium tab (supplement), Vitamin B 6 (health maintenance), melatonin (promotes sleep) and mometasone (for itching/skin irritation).  

On 9/15/21 the need to evaluate resident's ability to safely administer their own medications, and to ensure all self-administered medications were included in the physician's order of approval was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services).  They acknowledged the findings.

1. Resident's #1 and 4, order received from physician directing ability to self medicate.

2. New Move-In orders will be reviewed by DHS-RN and Health Services Staff to ensure compliance.

An audit of all residents who self-medicate will be completed monthly.

3. Quality Assurance will be completed monthly.

4. RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure residents who self-administered medications, and had more than one resident in a unit, were evaluated for safety on a quarterly basis and had physician's orders to self-administer medications, for 2 of 2 sampled residents (#s 8 and 9) who were reviewed for self-administration. This is a repeat citation. Findings include, but are not limited to:

1. Resident 8 was admitted to the facility in 06/2021 with a diagnosis of osteoporosis.

During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) reported Resident 8 administered his/her own medications.

Review of Resident 8's records revealed there was no physician order for the resident to self-administer medications. There was no documented evidence the resident was  re-evaluated for his/her ability to safely self-administer medications on a quarterly  basis.

2. Resident 9 was admitted to the facility in 06/2021 with a diagnosis of diabetes.

During the acuity interview on 01/31/22, Staff 3 (Health Services Assistant) reported Resident 9 and Resident 8 shared an apartment, and Resident 8 administered Resident 9's medications.

Review of Resident 8's and Resident 9's clinical records revealed Resident 8 had not been evaluated to determine if s/he was able to safely administer medication to Resident 9. There was no documented evidence of a physician order for Resident 8 to administer medications to Resident 9.

The need to ensure residents who self-administer medications, and had more than one resident in a unit, were evaluated for safety on a quarterly basis and had physician's orders to self-administer medications was discussed with Staff 1 (Administrator) and Staff 19 (Resident Services Coordinator/LPN) on 02/02/22. They acknowledged the findings. Resident 8 and 9 were evaluated for safety, and the facility requested orders form the residents' physicians.

1. Resident # 8 and #9 - order received from physician directing ability to self medicate and evaluation from LPN completed.

2. New move in orders will be reviewed by HSD - LPN to ensure compliance prior to resident being admitted.

Audit of all residents who self - medicate will be completeed montly.

3. Quality Assurance will be completed monthly.

4. HSD and Administrator

Based on interview and record review, it was determined the facility failed to ensure documentation that 3 of 4 sampled newly-hired employees (#s 13, 14 and 15) completed pre-service orientation or dementia care training prior to assuming their job duties. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Administrator) on 9/14/21. The following deficiencies were identified:

1. Staff 13 (Kitchen Aide) was hired 7/7/21. There was no documented evidence Staff 13 completed the following training requirements:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Oregon Food Handler's training; and

* That Staff 13 was provided a written job description.

2. Staff 14 and Staff 15, both Resident Assistants who provided direct care to residents, lacked documented evidence they completed approved pre-service dementia training prior to providing care to residents.

The need to ensure documentation of completed pre-service training was reviewed with Staff 1 on 9/15/21. She acknowledged the lack of training documentation.

1. Audit completed of new hire orientation pre-service requirements.

Current staff will complete all requirements of pre-service training.

2. Reimplement orientation process which includes all required elements.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 20, 21 and 22) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/31/22 and revealed the following:

a. There was no documented evidence Staff 20 (RA), Staff 21 (RA), and Staff 22 (RA), hired 10/19/21, 11/23/21, and 10/29/21 respectively, had completed one or more of the following required topics prior to beginning their job responsibilities:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures; and

* Written job description.

b. There was no documented evidence Staff 20 and Staff 22 completed all pre-service dementia training prior to providing care to residents.

The need for staff to complete all required pre-service orientation and dementia training prior to starting their job duties and providing care to residents was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

1. Audit of new hire orentation pre-service requirements.

All new hired staff will receive job descriptions and complete pre-service training before being put on staff schedule, as well as any other required elements.

2. Reimplement orientation process with includes all required elements of pre-service training.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 14, 15 and 16) completed all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 9/15/21 with Staff 1 (Administrator). The following deficiencies were identified:

1. Staff 14, a Resident Assistant who provided direct care to residents, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire.

2. Staff 14, 15 and 16, Resident Assistants who provided direct care to residents, lacked documented evidence of having completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure documentation of completed competency and Fist Aid training within 30 days of hire was reviewed with Staff 1 on 9/15/21. She acknowledged the lack of training documentation.

1. Audit completed of training first 30 day requirements.

Current staff will complete all first 30 day requirements.

2. Reimplement Competency Evaluation process which includes required elements.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 20 and 22) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 01/31/22 and the following was identified:

There was no documented evidence Staff 20 (RA), hired 10/19/21, and Staff 22 (RA), hired 10/29/21, had completed one or more of the following required competencies within 30 days of hire:

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* First aid/abdominal thrust.

The need to ensure there was documented evidence staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 18 (Assistant Administrator) on 02/02/22. They acknowledged the findings.

1. Audit completed of training first 30 day requirements.

Current staff will complete all first 30 day requirements.

2. Reimplement Competency Evaluation proess which includes required elements.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included all required information and components. Findings include, but are not limited to:

Fire and life safety records for April - August 2021 were reviewed on 9/15/21. Fire drill records lacked consistent documentation of the following required information:

* Escape route used;

* Evacuation time needed;

* Resident evacuation problems encountered; and

* Number of occupants evacuated.

The need to ensure fire drill records included all required information was discussed with Staff 1 (Administrator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the findings.

1. All-staff meeting in October where fire safety is topic. The form will be amended to ensure all required documentation is included.

2. Fire drills will be held per policy and regulation. Fire and life safety instruction will be provided on alternate months, from fire drills, during all-staff meeting.

A list and schedule for fire and life saftety topics will be developed.

3. Quality Assurance audits will be completed monthly.

4. Administrator.

Based on observation, 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 C252, C260, C270, C325, C370 and C372.

1. Community will be in compliance by 3/20/2022 for all applicable citations.

Plan of correction will be submitted to Division within ten days of inspection receipt.

2. Quality Assurance program will be restarted for all applicable departments.

3. Quality Assurance audits will be performed monthly.

4. Administrator.

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways in good repair. Findings include, but are not limited to:

The exterior of the building was toured on 9/13/21. There were multiple sections of the concrete path that encircled the building that had drop-offs from the surface of the path to the planting bed of up to two inches. This represented a fall risk for residents.

The drop-offs were reviewed with Staff 1 (Administrator), Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the drop-offs.

1. Drop-off areas will be leveled.

2. Reimplementation of Maintenance/Administrator weekly walk throughs with identification of needs.

3. Weekly walk throughs.

4. Maintenance Director and Administrator.

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

The interior of the building was toured on 9/13/21. The following areas needed repair:

* Door frames or doors of rooms 103 and 243, the staff laundry room and the exit door near room 130 were scuffed or gouged.

* Sections of the hallway handrails across from or near rooms 111, 119, 127, 128, 137 and the intersection of the hallway with room 206 where gouged and missing paint, leaving a rough surface.

The condition of the doors, doorframes and handrails were reviewed with Staff 1 (Administrator), Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the areas needing repair.

1. Door frames/Doors of rooms 103, 243, staff laundry and the exit door near room 130 will be repaired.

The hallway handrails across near 111, 119, 127, 128, 137 and the hallway intersection near room 206 will be repaired.

2. Reimplementation of Maintenance/Administrator weekly walk throughs with identification of needs.

3. Weekly walk throughs.

4. Maintenance Director and Administrator.  

Based on observation and interview, it was determined the facility failed to ensure covers of wall heaters did not exceed 120 degrees Fahrenheit (F) when installed in locations that are subject to incidental contact by individuals. Findings include, but are not limited to:

The interior of the building was toured on 9/13/21. Room 220, a one-bedroom unit, had a baseboard heater under the window in the bedroom. When the heater was turned on and allowed to heat up, the metal surface of the heater reached 139 degrees F. The heater was located where a resident could come into incidental contact with the hot surface of the heater. The facility provided information that indicated there were a total of 48 one-bedroom rooms that had similar baseboard heaters.

The risk posed by the hot surface of the baseboard heaters was discussed with Staff 1 (Administrator) on 9/13/21, and with Staff 17 (Maintenance Coordinator) and Staff 4 (Director of Nursing Services) on 9/15/21. They acknowledged the surface of the heaters exceeded 120 degrees F.

1. Plastic covers will be provided for the baseboad electrical heaters.

2. The system will be corrected when the heaters have been covered. Will replace covers if they become broken or unusable.

3. Covers will be inspected weekly by housekeepers during housekeeping services.

4. Maintenance Director and Administrator.