Print Inspection: LPOQ

The findings of the Change of Ownership survey conducted 06/12/23 through 06/14/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the revisit to the re-licensure survey of 06/14/23, conducted 03/26/24 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations were reflective of the resident's health status, current needs or addressed all required components for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose new move-in or quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2016 with diagnoses which included diabetes.

Observations, resident and staff interviews, and review of the record was conducted during the survey.

The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* History of dehydration or unexpected weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

On 06/14/23, the need to ensure Resident 2's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings.

2. Resident 3 moved into the facility in 01/2023 and had diagnoses which included dementia.

Observations, resident and staff interviews, and review of the record was conducted during the survey.

The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:

* Customary routines: sleeping;

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Mental issues including: Presence of depression, thought disorders or mood problems;

* Pain: Pharmaceutical and non-pharmaceutical intervention, including how the resident expressed pain or discomfort;

* Fall risk history;

* Complex medication regimen;

* Unsuccessful prior placements;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

On 06/14/23, the need to ensure Resident 3's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema.

Review of the most recent evaluation dated 06/05/23 revealed the evaluation was not reflective of the resident's health status, current needs, or did not address the required components in the following areas:  

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

* Visits to health practitioner(s), ER, hospital or NF in the past year;

* Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions;

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

* Ability to use call system;

* Recent losses;

* Unsuccessful prior placements;

* Elopement risk or history;

* Smoking, ability to smoke safely;

* Alcohol and drug use; and

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

The need to ensure Resident 1's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

4. Resident 4 was admitted to the facility in 04/2023 with diagnoses including Type 2 diabetes and Parkinson's Disease.  

Review of the initial evaluation dated 04/21/23 revealed the following elements were missing:

* Spiritual, cultural preferences and traditions;

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

* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.

The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

1.  All required components of the evaluation tool have been implemented and are in use for all new resident move-ins as well as quarterly evaluations. Residents 1,2,3 & 4 will be evaluated using the new tool and all required components have been addressed.

2.  The evaluation tool has been implemented with all new resident move-ins and incorporated in quarterly service plans on our routine schedule.

3.  All evaluations will be reviewed for completion during the routine move in process, significant change of condition or the routine service plan schedule.

4.  HCC and Administrator will be responsible for monitoring process as outlined above.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3 and 4's current service plans were reviewed during the survey.

On 06/14/23 at 11:00 am, Staff 1 (Administrator) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plan.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1.  A Service Planning Team has been put in place for Residents 1,2,3, and 4 along with all residents in the community, which includes documented evidence of team member participants.

2.  All Service Plan Team members will review service plan and document revisions based on resident evaluation prior to resident scheduled care conference. Service Plan Team will sign service plan discussed with resident, family and participants attending care conference.

3.  The system will be evaluated weekly as the Service Plan Team works throught the care planning calendar.

4.  Health Care Coordinator and Administrator will audit Service Plan book monthly for evidence of Service Plan Team participation.

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

Resident 1 moved into the facility in 2021 and had diagnoses including chronic obstructive pulmonary disease and emphysema.

Resident 1's MARs were reviewed for the time period of 05/01/23 through 06/12/23.

Staff documented Resident 1 refused the following for the month of 05/2023:

* Diltiazem (for blood pressure) on 22 occasions;

* Escitalopram (for depression) on 13 occasions;

* Furosemide (for pulmonary edema) on 13 occasions;

* Hydralazine (for blood pressure) on 22 occasions;

* Levothyroxine (for hypothyroidism) on 13 occasions;

* Omeprazole (for stomach care) on 13 occasions;

* Docusate (for constipation) on six occasions;

* Ferrous sulfate (for iron deficiency) on 14 occasions;

* Boost pudding (for muscle weakness) on 11 occasions;

* Eliquis (for blood clot prevention) on 23 occasions; and

* Levetiracetam (for seizures) on 21 occasions.

Staff documented Resident 1 refused the following for the time period of 06/01/23 through 06/12/23:

* Diltiazem (for blood pressure) on three occasions;

* Hydralazine (for blood pressure) on three occasions;

* Eliquis (for blood clot prevention) on one occasion; and

* Levetiracetam (for seizures) on three occasions.

In an interview on 06/13/23, Staff 4 (RCC) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals.

The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.  

1. Medications for Resident 1 have been reviewed by RN, Consultant Pharmacist and Consulting RN.  Physician has been notified of history and pattern of refusals and recommendations have been made for prescribing PRN medications when appropriate.  

2.  All Med Techs have been in-serviced on the need to notify physicians of refusals per order as outlined in the Service Plan.  Refusals are to be noted appropriately in Resident's Progress Notes and physician communication will be tracked through pending notification faxes.

3.  Missed Medication notes will be reviewed per electronic health record (PCC) to track medication refusals at least 3-5 times a week.

4. Process will be monitored and confirmed by RN.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications for behaviors. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 04/2016 with diagnoses including depression and anxiety.

Resident 2 had a physician's order for Clonazepam 0.5 mg one twice daily as needed for anxiety.

Review of MARs and progress notes, from 05/01/23 through 06/12/23, revealed staff administered PRN Clonazepam on 57 occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 on 06/14/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema.

Resident 1 had a physician's order for Lorazepam 0.5 mg tablet by mouth four times daily as needed for agitation, anxiety or shortness of breath.

Review of MARs from 05/01/23 - 06/12/23 revealed staff administered PRN Lorazepam on one occasion. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.

In an interview on 06/13/23 at 1:00 pm, Staff 4 (RCC) reviewed the MAR and progress notes. She acknowledged staff did not document non-drug interventions attempted prior to administering the PRN.

The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1. Non pharmacological interventions to employ prior to use of psychotropic medications to treat Resident 1 and Resident 2 have been detailed in their respective service plans and MAR's (medication administration record).

2. Caregivers and Med Techs have been in-serviced on the need to employ non pharmacological interventions in all scenarios prior to use of psychotrophic interventions.  Med Techs will document intervention effectiveness as evidenced by observations in progress notes before each Psychotropic Medication administration.

3.  Non pharmacological interventions will be re evaluated quarterly or as needed with service plan review.

4.  Process will be monitored and followed up by RN and Administrator.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented other less restrictive alternatives prior to use, provided instruction to caregivers on correct use and precautions, and documented use of the rails in the resident's evaluation and service plan for 1 of 1 sampled resident (# 1) who had side rails.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema.

During an interview on 06/13/23 at 12:10 pm, Resident 1's hospital bed was observed to have half-length side rails on the left side of the bed. The side rails were in the up position and securely fastened to the bed.

In an interview with Staff 1 (Administrator) on 06/13/23 at 4:30 pm, side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.

The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

1.  A Supportive Device Assessment with potentially restraining qualities has been completed on

Resident 1.  Less restrictive alternatives have been discussed with hospice, findings have been documented in health record and service plan has been updated.

2.  A supportive device assessment with restraining qualities audit will be performed for all residents.  Assessments will be completed as necessary and care plans have been updated.

3.  All pending orders will be reviewed by RN and assessments will be performed prior to implementing any orders for restraints.  All staff have been in-serviced on the identification of supportive devices with portentially restraining qualities.  New hire staff have identification of supportive devices in their 30 day training.  Reassessment of each resident with supportive devices with potentially restraining qualities will be reviewed quarterly.

4.  Process will be monitored by RN and Administrator.

Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 sampled newly hired employees (#s 9, 10, 11 and 12) completed pre-service orientation and dementia care training prior to assuming their job duties. Findings include, but are not limited to:

Staff training records were reviewed on 06/13/23. The following deficiencies were identified:

a. Staff 9 (CG), hired 03/02/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training.

b. Staff 10 (CG), hired 04/28/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training.

c. Staff 11 (MT), hired 04/05/23, lacked documented evidence of having completed Infectious Disease Prevention training.

d. Staff 12 (Waitstaff) was hired 05/22/23. There was no documented evidence Staff 12 completed the following training requirements:

* Fire Safety and emergency procedures; and

* Infectious Disease Prevention.

The need to ensure staff completed pre-service training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23 at 3:30 pm. They acknowledged the findings.

1.  Staff 9, 10 and 11 will complete required preservice Dementia Care and Infectious Disease Prevention training.  Staff 12 will complete Fire Safety and Emergency procedure in-person in-service and Infectious Disease Prevention training.

2.  An audit of all current staff has been conducted and non-compliant staff have been scheduled to complete required training

3.  A new employee pre-employment orientation and training process has been developed and implemented.  As part of that program, staff will complete required pre-service training prior to being placed on the schedule for regular duties.  Compliance will be tracked in "Employees at a Glance".

4.  "Employees at a Glance" will be reviewed monthly at routine staffing meeting between The Staffing Coordinator and the Administrator to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 10 and 11) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 06/13/23.

There was no documented evidence Staff 10 (CG) and 11 (MT), hired 04/28/23 and 04/05/23 respectively, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

Additionally, there was no documented evidence Staff 10 had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23. They acknowledged the findings.  

1.  Competency evaluations including all required components will be completed for Staff 10 and 11.  Completed competency evaluations will be placed in their employee files.

2.  An audit of all direct care staff has been completed and non-compliant staff will demonstrate competencies for all required components.  Updated competency evaluations will be included in their employee files.

3.  A new employee pre-employment orientation and training process has been developed and implemented.  At the completion of that program, staff will complete competency evaluations.  Compliance will be tracked in "Employees at a Glance".

4.  "Employees at a Glance: will be reviewed monthly at routine staffing meeting between the Staffing Coordinator and the Administrator to ensure compliance.

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

Fire and life safety records, reviewed between 01/2023 through 06/2023, revealed the following:

* Fire drill records lacked the following components:

- Escape route used;

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

- Evacuation time period needed;

- Number of occupants evacuated; and

- Evidence alternate routes were used during fire drills.

In an interview on 06/13/23 at 2:45 pm, Staff 1 (Administrator) acknowledged fire drill records lacked the required components.

1.  A New Fire Drill tracking form has been implemented that includes all required elements as outlined in OAR 411-054-0090.

2.  The new form has been implemented for all Monthly Fire Drills and has been in use since July 1, 2023 and has been completed by all participating parties.

3.  A Fire Drill schedule has been calendared to include scheduled, unannounced Fire Drills on a monthly basis.  Drills will rotate through all three shifts and evacuations performed on day shift and swing shift drills.

4.  The Fire Drills will be monitored by the Administrator.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training annually. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 06/13/23 at 2:45 pm. She acknowledged the findings.

1.  Existing residents will be instructed on Fire and Life Safety procedures including evacuation methods, responsibilities during drills and designated meeting spaces.

2.  All residents will be oriented to Fire and Life Safety procedures upon move-in and will be performed within the first 24 hours.

3.  Annual resident in-servicing will be conducted in July for all residents.  Instruction options will include in-person, one-on-one discussions, group discussions and written instructions.

4.  Resident Orientation will be conducted the the Activity Director and overseen by the Administrator.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to:

Observations of the outer courtyard surfaces and pathways on 06/12/23 showed the following:

* Multiple drop-offs of 2-4 inches along pathway edges of the courtyard.

The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) and Staff 2 (Owner) during a tour of the exterior grounds on 06/13/23 at 11:40 am. The findings were acknowledged.

1.  A landscaping company has been contracted with to blow in bark dust to level drop-offs along the edge of pathways in the courtyard.

2.  All exterior paths will be reinforced to level up drop-offs and potential drop-offs to prevent future issues.

3.  Walk way edges will be monitored through routine walk-abouts and quarterly audits.

4.  The Maintenance Director will be responsible for monitoring walk way edges and the process will be overseen by the Administrator.

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

The facility was toured on 06/12/23. The following was observed:

* Lower cabinets in the activity room were scraped/scuffed;

* Cabinets in the dining room were scraped/scuffed;

* Tables throughout the dining room were scraped on the edges;

* Chairs throughout the dining room were scraped/scuffed;

* Carpet in front of Room 109 was stained;

* Baseboard that surrounded RCC desk area was scuffed;

* Spills on the wall by the door to the outside in the hallway of Room 125;

* Inside the elevator had boards around the base that were scuffed and gouged;

* Multiple doors leading to the exterior had gouged, scuffed door jambs and doors;

* A couch in the 2nd floor library was stained; and

* A wall outside of Room 233 had gouges.

The environment was toured on 06/13/23 at 11:40 am with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the above areas needed to be cleaned and repaired.

1.  Cabinet Doors in the Activity Room and the Dining Room will be sanded and re-stained.  Table edges will be re-stained.  Chairs in the Dining Room are in the process of being recovered and legs will be re-stained.  Stains in the carpet and library couch will be pointed out to cleaning company to address problem areas.  Walls, doors, baseboards have been cleaned and paint will be touched up where necessary.

2.  Staff has been in-serviced on reporting issues to Housekeeping or Maintenance when issues are identified.

3.  A routine preventive Maintenance schedule has been implemented to continously address issues as they arise.

4.  The Maintenance Director and Housekeeping Supervisor will be reponsible for ongoing monitoring and cleaning of building and furnishings.  Administrator will maintain oversight through routine walk throughs and review of Maintenance and Housekeeping logs.