Print Inspection: M3QJ

The findings of the re-licensure survey conducted 07/10/23 through 07/12/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 07/12/23, conducted 05/22/24 through 05/24/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 07/12/23, conducted, 08/15/24, are documented in this report. It was determined the facility was in 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.

Based on interview and record review, it was determined the facility failed to implement effective methods of responding to and resolving resident complaints. Findings include, but are not limited to:

Resident Council Meeting notes dated 04/10/23 through 07/07/23 revealed the following resident concerns:

* "Stuff [laundry] not getting put in right spots";

* "Front bathroom not getting cleaned";

* "More diabetic options";

* "More jello or pudding";

* "More decorations in dining room";

* "More pictures in dining room";

* "Some freezers [in resident rooms] need defrosted";

* "Complaints that laundry is not getting put away";

* "Showers are being done when convenient for staff rather than when scheduled";

* Want "better diabetic meals and desserts";

* "Residents want more rolls included in meals" and "want the lunch big meal served at dinner";

* "Want to do new things [activities]";

* "Salads have been skimpy depending on who works";

* "Would like entertainment back"; and

* "Would like more crafts ..."

There was no documented evidence the concerns identified during the meetings had been addressed, responded to, or resolved.

On 07/11/23, the survey team conducted a group interview with eight alert and oriented facility residents. Multiple members of the group stated the Administrator did not respond to complaints or suggestions brought up in Resident Council. They said the Administrator did not provide feedback to resolution when complaints/suggestions were brought to her attention.

In an interview on 07/12/23 at 8:15 am Staff 1 (Administrator) said resident concerns or suggestions were passed along to the respective department head. She acknowledged the lack of documented follow-up or response to complaints or suggestions.

C154-OAR 411-054-0025 POLICES & PROCEDURES

Actions that were taken to correct the rule violation include:

1. Creating a resident council meeting form with a side for the complaints to be recorded. The back side of the form is the response plan that will initiated to solve the problem.

2.  Having a regularly scheduled resident council meeting on the first Monday of every month. This will help Director to stay on top of the complaints, and to make the residents feel that their voice is heard and that the problems will be solved.

3. After the complaints have been noted; Director will then go over the isssues with staff on changes that need to be made and how to implement them at the monthly staff meeting. Director will then post the resident council minutes in a secure area for the staff to have a reminder of the changes that need to be made that month. Going over the past month responses from the residents on how the staff did on implementing/correcting the suggestions from the previous month so staff know what they need to work on and what was a success.

4. At the following resident council meeting the Director will go over the previous complaints form with the residents and ask them if the problem/concerns have been resolved. If not the Director will go over other options until the issue(s) have resolved.

2. Resident 6 was admitted to the facility in 01/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident was discharged from hospice on 05/20/24.

A review of the resident's clinical record from 02/09/24 through 05/02/24 and resident and staff interviews identified the following:

* The Service Plan dated 04/03/24 indicated the resident "has mild to moderate disorientation and difficulty recalling/retaining information."; and

* A Progress Note dated 02/22/24 stated: "nose was swollen and dried blood on the nose up towards R [right] eye. Both knees are skinned and have abrasion on them. There is also bruising on both knees and around open wound near R [right] eye on [his][her] nose...This is an unwitnessed fall."

During an interview on 04/24/24 with Resident 6, the resident had difficulty communicating and was unable to provide information about the incident on 02/22/24.

The incident on 02/22/24 represented an injuries of unknown cause.

There was no documented evidence the facility immediately investigated the injuries to rule out abuse or reported them to the local SPD office as suspected abuse.

The need to ensure resident incidents were immediately investigated by the facility to reasonably conclude and document that the physical injuries were not the result of abuse and reported to the local SPD office as needed was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

Based on interview and record review, the facility failed to have policies and procedures in place to assure the prevention and appropriate response to any incident, report physical injuries of unknown cause to the local (SPD) office as suspected abuse unless an immediate facility investigation reasonably concluded and documented the physical injuries were not the result of abuse for 2 of 3 sampled residents (#4 and #6). Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2017 with diagnoses including muscle weakness.

A review of the resident's clinical records, from 03/03/24 through 05/20/24 revealed s/he had a fall on 03/03/24 and on 05/07/24, resulting in injuries.  

The 03/03/24 progress note stated "Resident had fallen in [his/her] room at the end of [his/her] as yelling for help when another resident heard [him/her] and came to get staff. When I found [him/her], [s/he] stated [s/he] wasn't in any pain but that [s/he] hit [his/her] head on a stand. When I asked how [s/he] had fallen [s/he] said [s/he] slipped out of [his/her] wheelchair. [His/her] wheelchair was across the room and then later resident stated that [s/he] wasn't sure how [s/he] had fallen. I didn't see any injuries besides rug burn on [his/her] elbow". 911 was called and Resident 4 sent to the ER.

The 05/07/24 progress note stated "resident was transferring from [his/her] bed and missed the chair and fell forward scraping [his/her] head and both knees."

There was no documented evidence the facility immediately investigated the falls with injuries to rule out abuse nor were the incidents reported to the local SPD office.

On 05/23/24 at 10:35 am, in an interview with Staff 1 (Administrator) and Staff 2 (RN) they stated that staff had been trained to complete incident reports but they were only writing them as progress notes. Additionally they stated they had been reporting the local case manager but not to adult protective services (APS).

The facility was directed by the surveyor to report the incidents from 03/03/24 and 05/07/24. The facility provided confirmation the incidents had been reported to the local office on 05/23/24.

The facility's failure to report incidents of suspected abuse/neglect or injuries of unknown cause, or to conduct an immediate investigation of an injury of unknown cause and document that abuse was ruled out, was discussed with Staff 1 on 05/24/24. She acknowledged the findings.

1. Reported injury falls to APS- Residents, #104, #115, and #112. Angella Thatcher, care parter, used resident #103's Morphine. Investigation was done by RN and Director. Angelia admitted using Morphine. APS, caseworker and police were notified. Angela was immidately terminated.

2. Director, RCC, and RN taking class with APS on June 6th at 2:00. We will then train staff on how to report and what to report.

3. After each fall and at our monthly mandatory training meetings for all staff.

4. Ex Director or RN will be responsible to see that the corrections are being completed and monitored.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

a. Observation of the kitchen on 07/10/23 from 11:58 am to 12:20 pm, revealed the following areas needed cleaning:

* Two Profryers next to the ice maker had built-up grease and sticky matter on them;

* Stove knobs had spills and grease buildup;

* An air-conditioner unit at the window had a layer of dust;

* The ceiling vent had a layer of dust; and

* The metal can-opener, attached to the countertop, had an accumulation of brown matter and rusted metal.

b. During the tour on 07/10/23 at 1:10 pm, a bucket of sanitizer was tested with a facility test strip and the solution did not reach the required sanitizing level. Staff 13 (Cook) reported she used the wrong test strip, and she did not have the correct test strips to check the sanitizing solution.

On 07/11/23 at 2:30 pm, the surveyor toured the kitchen and reviewed the above findings with Staff 1 (Administrator). Staff 1 acknowledged the findings.

c. On 07/11/23 from 11:55 am to 12:25 pm, Staff 13 was observed and the following was noted:  

* Staff 13 prepared beef tacos with plastic gloved hands;

* During the preparation of the beef tacos, Staff 13 walked away from the tray line and went to the refrigerator and cabinet;

* Staff 13 grabbed the refrigerator handle and opened the drawers with the gloved hands;

* Staff 13 went back to the tray line without changing gloves or washing her hands;

* Staff 13 was observed touching tortillas and cheese with the same gloved hands;

* Staff 13 walked away from the tray line again, went to the microwave to use it and returned to the tray line without changing gloves or washing hands; and

* The surveyor intervened and requested that Staff 13 change gloves prior to resuming the tray line. Staff 13 washed her hands and changes gloves prior to resuming the tray line.

On 07/11/23 at 2:30 pm, the surveyor shared the above observation with Staff 1 (Administrator) and discussed the proper technique for the infection control practice. Staff acknowledged the findings.

d. On 07/12/23 at 8:10 am, the surveyor observed that soft cooked eggs were served to residents with regular eggs, not pasteurized eggs, during the breakfast. Staff 13 confirmed the facility did not use pasteurized eggs for soft cooked eggs.

On 07/12/23 at 10:20 am, the surveyor shared the above observation with Staff 1 (Administrator) and discussed the use of pasteurized eggs for soft cooked eggs. Staff 1 acknowledged the findings.

C 240-OR 411-054-0030 Resident Services Meals, Food Sanitation Rule

Actions that were taken to correct the rule violation include:

1. Pro-frys have been cleaned,moved to a designated area and have been added to the scheduled cleaning tasklist. Stove, A/C vent, and can opener were also cleaned. Now all cleaning has to be checked off that the task was completed and initialed and dated by staff.

2.Correct test strips will now be used for sanitation. New form for testing the buckets used for sanitation. Will include; date,time, level of solution that is required for sanitation and staff initals.

3. Kitchen staff trained on proper food preparation. If staff leave the tray line or any reason when they come back to the tray line they are to change their gloves, wash hands, and put on new gloves.

4. Kitchen manager now is ordering pasteurized eggs.

Director addressed the issues with all kitchen staff and will monitor.

Daily

Director and cooks

3. Resident 3 was admitted to the facility in 10/2021 with diagnoses which included diabetes.

Observations, an interview with the resident and staff, and review of the record during the survey revealed the most recent quarterly evaluation, dated 05/14/23, was not reflective of the resident's health status, current needs, or preferences in the following areas:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

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

* Ability to use call system;

* Skin condition;

* Complex medication regimen;

* History of dehydration or unexpected weight loss or gain;

* Recent losses;

* Unsuccessful prior placements;

* 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, room temperature.

On 07/12/23 at 10:50 am, the need to ensure Resident 3's evaluation was reflective of his/her health status, current needs, and preferences was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease.

The resident's most recent evaluation was dated 05/31/23. Observations of the resident, interviews with staff, a review of the resident's progress notes, dated 03/23/23 - 06/30/23, and the evaluation showed the evaluation was not reflective of the resident's current condition, needs and preferences in the following areas:

* Skin status;

* Frequent antibiotic use;

* Activity status;

* Ability to use call system;

* Use of oxygen including setting;

* Toileting status;

* Transfer status;

* Refusal of Ted hose status; and

* Ambulation status.

The need to perform evaluations with updates to health status, needs and preferences was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure resident quarterly evaluations were reflective of residents' health status, current needs, and preferences for 3 of 3 sampled residents (#s 1, 2 and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including cognitive communication deficit, dysphagia, and abnormalities of gait and mobility.

On 07/10/23, Staff 3 (RCC) was requested to provide an evaluation for Resident 1 dated more recently than 10/04/22. Staff 3 stated the current service plan dated 05/26/23 reflected the most recent evaluation. Review of the evaluation revealed it was not reflective of the resident's health status, current needs, or preferences in the following areas:

* Customary routine related to eating;

* Visits to health practitioners, ER, hospital, or nursing facility in the past year;

* Presence of depression, thought disorders, behavioral and mood problems;

* History of treatment;

* Effective non-drug interventions;

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

* Ability to understand and be understood;

* Dental status, and assistive devices;

* Recent losses; and

* Fall risk.

The need to ensure the quarterly evaluation was reflective of his/her health status, current needs, or preferences with sufficient information to develop a quarterly service plan was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 11:00 am. They acknowledged the findings. No further information was provided.

C252- OAR 411-054-0034 Resident Move-in and Eval: Res Evaluation

Actions that were taken to correct the rule violation include:

1. The facility has been transitioning over to a new system the last few months and are learning how to work/navigate the system. At the time of the state survey, the staff that were present did not know how to print out the residents level of care and evaluation. This will be remendied by training staff how to find updated resident charts as well as confirming updated documentation is being printed and put in the appropriate place for staff to review and have readily available.

2. Residents 1, 2, and 3 had updated service plans, level of care, and move in evaluation as well as 30 day and quarterly evaluations. The evaluations include all the info that is required by state. To populate a service plan, a level of care and evaluation have to be done first. However based on the findings from this survey we are finding the updates on the evaluation tool are not carrying over to the service plan.  To resolve this problem we have asked for more training in the new software system PointClickCare.  This training/retraining will include:

Initial Screening and Move-in Process

oWill retrain on move-in process in PCC, including digital move-in packet in Document Manager.  This packet includes all the required move-in paperwork and gets prefilled by PCC if the information is available in the system.  This will cut down on the time that it takes for the process.  The move-in packet includes but is not limited to the checklist needed to make sure all requirements are covered.  

oWill retrain to answer all questions in the evaluation even if resident does not need the service.  This will insure all ADLs are being reviewed and addressed in the evaluation as well as the service plan.  The completed evaluation covers all the required information for move-in.  During this review will also ensure all areas of ADLs will be carried over to the updated service plan.

oWill retrain on setting up evaluation schedule correctly, this will allow the system to track "Move-in, 30 day, 60 day and every 90 days" so the team and Director do not have to track in another location.  

All retrainings have been scheduled with the home office and have already started to take place.  They will continue for the next week and will be completed before resurvey.  During this time we will also make any necessary updates to evaluations and service plans that do not address all required information.  New Care Plan meetings will be scheduled with family/POA and reviewed before being distributed to staff for reviewed, signed and filed in the appropriate place.

Director, RCC, RN

3. Resident 3 was admitted to the facility in 10/2021 with diagnoses including diabetes.

Observations of the resident, resident and staff interviews, and review of the service plan available to staff dated 05/14/23, showed the service plan was not reflective of the resident's current care needs or did not provide clear direction to staff in the following areas:

* Interventions related to behavioral episodes;

* Elopement risk;

* Bathing assistance;

* Cognition and ability to make decision;

* Dressing assistance;

* Meal reminders;

* Ambulation assistance;

* Toileting assistance; and

* Transfer assistance and use of rails or devices on bed.

The need to ensure Resident 3's service plan was reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 07/12/23 at 10:50 am. She reviewed the service plan and acknowledged the findings.

2. Resident 2 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease.

Observations of the resident, interviews with staff, and review of the service plan, dated 05/31/23, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Use of overhead trapeze;

* Use of oxygen including setting;

* Toileting status;

* Smoking status;

* Transfer status;

* Outside provider services;

* Ambulation status; and

* Use of side rails.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) on 07/11/23 at 2:30 pm. The staff 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 directions to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including cognitive communication deficit, dysphagia, and abnormalities of gait and mobility.

Interviews with resident and staff, and review of the current service plan, dated 05/26/23, revealed Resident 1's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Behavioral problems;

* Number of staff needed to assist with activities of daily living;

* Hearing and use of assistive devices;

* Transfers;

* Dental status and assistive devices;

* How s/he expressed pain or discomfort; and

* Skin condition.

The need to ensure the service plan reflected residents' current needs and provided clear instructions to staff regarding delivery of services was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 11:00 am. They acknowledged the findings. No further information was provided.

C 260-OAR 411-054-0036 Service Planning Team

Actions to be taken to correct the rule violation include:

1. Facility converted to new software system within the last year, that included evaluation, level of care and service planning.

oRetraining on the evaluation and service plan process. These retrainings will ensure resident evaluations and care plans are completed timely and properly.

oRetraining Director, RN, RCC  on the Team Approach to develop accurate service plans.  This will also ensure a system is in place for all new service plans to be available to staff, each shift, staff will review and sign on signature page.  Once the service plan review has taken place with resident and family/POA it will be implemeneted for staff to follow as the plan of care.

oIntroducing digital move-in packet in PCC, will allow remote service plan reviews and digital signing.  This is to improve family involvement if they are unable to come on site.

PCC system tracks scheduling of Move-in, 30-day, 60 day, and every 90 days, as well as Change of Condition and SignCOC.  This will ensure scheduling, accuracy and provide a solid process.

Director, RCC and RN

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 directions to staff regarding the delivery of services for 2 of 4 sampled residents (#s 5 and 6) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and acute kidney failure. Resident 5 was dependent on renal dialysis.

Observations were made of the resident's care on 05/23/24. Interviews with facility staff and the resident were conducted. The current service plan dated 03/27/24 was reviewed.

Resident 5's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Dialysis port monitoring and precautions;

* Instructions for signs and symptoms of complications to report while monitoring dialysis port;

* Instructions on signs and symptoms of depression to report while on anti-depressant therapy;

* Instructions on signs and symptoms of hypo and hyperglycemia to report;

* Instructions for bleeding precautions and interventions while on anticoagulation therapy;

* Number of staff needed to assist with activities of daily living;

* Ambulation and use of assistive devices;

* Electric wheelchair equipment precautions and instructions for proper maintenance;

* Behavioral problems and effective non-drug intervention;

* How a person expresses pain or discomfort;

* Fluid preferences; and

* Recent losses.

The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 01/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident was discharged from hospice on 05/20/24.

Observations were made of the resident's care on 05/24/24. Interviews with facility staff and the resident were conducted. The current service plan dated 04/03/24 was reviewed.

Resident 6's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas:

* Oxygen equipment precautions and instructions for proper maintenance;

* Number of staff needed to assist with activities of daily living;

* Fluid preferences;

* Hearing; and

* Mobility and assistive devices.

The need to ensure the service plan reflected the resident's current needs and provided clear instructions to staff regarding the delivery of services was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

1. RCC went back through resident #111, #118, #113 and updated service plans with more details on what resident care needs are. #121 Passed away 5/25/24. 4/25/24 RCC completed a Relias Service Plan Training course and had 2 training sessions with corporate RN on what needs to be in service plans. When state was in they also talked with RCC and gave her some very useful information on how to correctly build a service plan.

2.This system will be corrected so this violation does not occur again will be continued education and training by RCC and having contact with with corporate RN to help look over SP and give advice and feedback.

3.Update every 3 months and as needed for changes of conditions.

4.Director, RN, and RCC will be responsible to see that the corrections are being completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility 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 2 of 3 sampled residents (#s 1 and 3). Findings include, but are not limited to:

Resident 1 and 3's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 11:00 am. They acknowledged the findings. No further information was provided.

C 262- OAR 441-054-0036 Service Plan Team

Actions to be taken to correct the rule violation include:

1.Service Plan team will include the resident, legal representative, RN,RCC and Director to go over all care needs before Service Plans are updated to make sure they match the residents care needs and preferences.

2. Service plan team will use tools that will contain all information that is required by state. Service plan team will also make sure all point are addressed, corrected and updated, prior to revisions being made to the service plan.

3.  Retraining in software system will also benefit in this area. RN, Director and RCC, will also be trained on how to audit the software system to consistantly improve service plans and evaluations.

Director and Service Plan Team.

3. Resident 3 was admitted in 10/2021 with diagnoses which included diabetes, fibromyalgia, insomnia, and arthritis.

Resident 3's clinical record and charting notes, reviewed from 03/30/23 through 06/23/23, revealed s/he had had several medication changes. The facility initiated short-term monitoring. However, no monitoring until resolution was documented for the changes in condition.

Additional information was requested on 07/11/23.

On 07/11/23 at 10:45 am, Staff 2 (RN) reported she reviewed the resident's record and concluded the short-term changes in condition had not been monitored until resolved.

Failure to monitor short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) on 07/12/23 at 10:50 am. She acknowledged the findings. No further information was provided.

2. Resident 2 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease. Resident 2 required a walker for mobility.

Progress notes and Temporary Service Plans (TSP) dated 03/23/23 through 06/30/23 indicated the following:

* 03/17/23: Changed dose in Parkinson's disease medication;

* 04/21/23: Antibiotic use for urinary tract infection; and

* 06/25/23: An antibiotic use.

There was no documented evidence the changes were monitored through resolution.  

On 07/11/23, the above findings were reviewed with Staff 1 (Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to document weekly progress until the condition resolved for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed with short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including cognitive communication deficit, dysphagia, and abnormalities of gait and mobility.

Resident Service Notes from 03/2023 through 06/2023 and a Incident Report and Investigation dated 05/17/23 were reviewed and revealed the following:

On 05/17/23, Resident 1 experienced an unwitnessed fall with injury in his/her apartment resulting in bruising and rug burn to the right shoulder.

Resident 1 had a short-term change of condition related to the shoulder injury. There was no documented evidence of weekly progress noted until the bruising resolved.

The need to ensure the facility monitored the short-term change of condition with weekly progress noted until resolution was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 11:00 am. They acknowledged the findings. No further information was provided.

C 270-OAR 411-054-0040 Change of Condition

Actions to be taken to correct the rule violation include:

1. Staff Pre Service training on how to correctly chart/documention and make sure they chart on any change of conditon, short term or long, medication changes, hospital visits, hospital admins, doctor visits, etc.

2. Residents to be monitored and documented on for duration that RN implements and are to be closed when duration is up or resolved, closed by the RN. Proper documentation will be in the residents service notes.

3. RN will receive more training to ensure she is properly following up on all changes, documentation, and resident service notes.

4. Home office will prove additional training on new softeare.  These tools will make it easier to track more efficiently and effectively.  Retraining will include but not be limited to:

oPCC has a process for Change of Condition, will train Director,RCC,RN on how to use change of condition templates available in PCC.  Will train staff to use progress notes, care plans and alert charting to track COC and review when resolved.  Training will also demonstrate to staff how to chart any changes on resident digital chart for supporting documentation.

oDirector and RN will receive training when to use Significant Change of Condition templates and the process to get evaluation, service plan and resident charts updated properly with the change.

oTraining will demonstrate, how to track the COC templates and progress notes by staff.

Daily RN and Director oversight

RN and Director will be responsible for following up on all changes.

Based on observation, interview, and record review, it was determined the facility failed to evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed for a significant change of condition, and failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, and document progress until the condition resolved for 4 of 4 sampled residents (#s 4, 5, 6, and 7) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and acute kidney failure. Resident 5 was dependent on renal dialysis.

Clinical records, including the current service plan, dated 03/27/24, progress notes from 02/11/24 through 05/17/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

02/11/24: visit to ER, started antibiotic therapy for urinary tract infection;

02/13/24: progress note recorded " ...continues to have emesis, not related to ABX [antibiotic]";

02/14/24: discontinued Keflex 500mg (antibiotic) and started Bactrim (antibiotic);

02/23/24: visit to ER, started Valium 5mg as needed for dizziness and Zofran 4mg as needed for nausea and vomiting;

02/25/24: nausea and vomiting;

02/29/24: dialysis fistula procedure at CHI Mercy Medical center;

03/15/24: dose changes to long-acting and short-acting insulin;

03/18/24: progress note recorded " ...has been vomiting.";

03/26/24: new medication order for megestrol (appetite stimulant);

03/27/24: progress note recorded "throw up after Megestrol, refused.";

03/30/24: progress note recorded "refused again Megestrol";

04/06/24: unwitnessed non-injury fall; and

05/10/24: discontinued amlodipine (for blood pressure) and decreased dose of losartan (for blood pressure).

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 01/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident was discharged from hospice on 05/20/24.

Clinical records, including the current service plan, dated 04/03/24, progress notes from 02/09/24 through 05/02/24, and outside provider notes were reviewed, and interviews with facility staff were conducted.

The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and/or documented weekly progress until the condition resolved:

02/08/24: visit to emergency room (ER) related to gastritis;

02/09/24: new order for omeprazole (for gastric ulcer) for 30 days;

02/09/24: progress note recorded " ...[resident] has been in extreme pain this ..shift.";

02/09/24: progress note recorded "found [resident] confused standing naked, hold ..stomach cause  ...was in pain";

02/10/24: progress note recorded " [resident] has been in pain, grabs at  ...right side"

02/11/24: progress note recorded " ...still hurts on the right side";

02/11/24: progress note recorded "[resident] got very winded and started hurting";

02/12/24: progress note recorded "does not look like [resident] is very well";

02/14/24: visit to ER related to dehydration;

02/22/24: unwitnessed fall, progress note recorded "nose was swollen and dried blood on the nose up towards R [right] eye. Both knees are skinned and have abrasion on them. There is also bruising on both knees and around open wound near R [right] eye on [his/her] nose"; and

04/29/24: started furosemide (diuretic) for edema of lower extremities.

The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

3. Resident 4's progress notes dated 03/03/24 through 05/20/24 revealed the resident experienced the following changes of condition:

* 03/03/24 Unwitnessed fall with injury;

* 05/02/24 Wound to heel; and

* 05/07/24 Unwitnessed fall with injury.

The facility failed to investigate the circumstances for the falls or heel wound to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.

The need to ensure the facility had a system to determine if interventions were needed and documenting changes of conditions at least weekly until resolved was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 05/24/24. They acknowledged the findings.

4. Resident 7 was admitted to facility in 12/2022.

Resident 7's clinical record and charting notes, reviewed from 12/19/23 through 05/22/24, revealed the following:

a. Resident 7 started antibiotics on 02/15/24 and again on 03/16/24. Although alert monitoring was initiated for the change, there was no documented monitoring of resident's condition until resolution.

b. Resident 7 was identified for a rash under abdominal fold on 04/14/24. The facility failed to determine if service-planned interventions were implemented, were effective or if new interventions were needed, and failed to communicate determined actions/interventions to staff on each shift. Additionally, there was no documented evidence the facility consistently monitored and documented on the progress of the resident's condition at least weekly until resolved.

The need to ensure short term changes of condition were monitored until resolution, interventions were determined, documented, communicated to staff on each shift, and reviewed for effectiveness was shared with Staff 1 (Administrator) and Staff 2 (RN) on 05/23/24. They acknowledged the findings.

1.RN has had additional training from corporate RN with changes of conditon/ monitoring and now is aware of what needs to be done. RN will check TSP's daily and will add additional information of what staff need to be looking for and when to report to the RN with any concerns. RN will also determine if change of condition is temporary or if SP needs to be updated to a permit change. RN will document on TSP when closing alert charting.

2.TSP will be checked daily by RN to monitor documentation is correct, completed, and D/Cd when appropriate with her closing the TSP

3.Nurse will document weekly until resolved once off Alert Charting.

4.RN will be responsible to see that the corrections are completed/monitored and that all staff are documenting correctly.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment had been completed for 2 of 2 sampled residents (#s 4 and 7) who had a significant change of condition. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2017 with diagnoses including dementia and muscle weakness.

Review of the resident's 03/03/24 through 05/20/24 progress notes showed the following:

* Resident 4 was admitted to the hospital 03/03/24 and returned to the facility on 03/06/24 with a catheter.

* Resident 4 was admitted to the hospital 03/22/24 and returned to the facility 04/29/24 with a new diagnosis of multiple mini strokes (TIA). Resident 4 had a significant change of condition due to a decline in his/her ADLs and cognition.

Resident 4 had a significant change of condition upon return from the hospital, as s/he could no longer ambulate without a wheelchair. Previously the resident could ambulate with a walker. There was no documented evidence the RN had completed an assessment for either significant changes of condition.

On 05/23/24, in an interview with Staff 2 (RN), the scope of an RN assessment when reviewing a significant change of condition was discussed.

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 on 05/24/24. They acknowledged the findings.

2. Resident 7 was admitted to the facility 01/2022 with diagnoses that included multiple sclerosis and falls.

Review of the resident's progress notes from 12/19/23 through 05/22/24 revealed Resident 7 had an unwitnessed fall that resulted in injury. Resident was sent to the ER.

Resident 7 returned fro the hospital with a new diagnosis of a shoulder fracture. This was a significant change of condition.

There was no documented evidence the RN had completed an assessment for this significant change of condition.

On 05/24/24, in an interview with Staff 2 (RN), she stated that there was no RN assessment.  

The need to have an RN assessment for a significant change of condition was reviewed with Staff 1 (Administrator) and Staff 2 on 05/24/24. They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident?1.Significant Change of Condition will be monitored by RN daily and will be charted on weekly until resolved. RN will then decide if change of condition will be permanent or temporary and will document accordingly. SP will be updated if change of condition will be permanent.

2.RN will be monitoring daily and charting weekly.

3.RN will document weekly and at the end of every month will go through and make sure nothing was missed and all updates and prog notes are in and correct as a 2 step verification process.

4.RN will be responsible to see tat the corrections are completed/monitored.

7/8/2024

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 2 of 2 sampled residents (#s 2 and 3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

1. During the acuity interview on 07/10/23, Resident 3 was identified to be administered insulin injections by non-licensed staff.

Resident 3's MARs, reviewed from 07/01/23 - 07/10/23, revealed insulin had been given by Staff 5 and 8 (MTs) on several occasions.

Review of Resident 3's delegation documentation on 07/11/23 revealed there was no documented delegation completed for Staff 5 and 8.

In an interview on 07/12/23 at 10:30 am, Staff 2 (RN) said she had not delegated Staff 5 and 8. She was unaware that both staff were giving insulin. Staff 2 stated Staff 5 and 8 would not give insulin until the delegation had been completed.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) on 07/12/23 at 10:50 am. She acknowledged the findings.

2. During the acuity interview on 07/10/23, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2's MARs, reviewed from 07/01/23 - 07/10/23, revealed insulin had been given by Staff 6, 7 and 9 (MTs) on several occasions.

Review of Resident 2's delegation documentation on 07/11/23 showed the information in the documentation was not related to Resident 2's condition.

In an interview on 07/12/23 at 10:20 am, Staff 2 (RN) reviewed the delegation documents and stated the information was not relevant to Resident 2. Staff 2 acknowledged the delegation document was not completed in accordance with OSBN.

The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (Administrator) and Staff 2 on 07/12/23 at 10:20 am. They acknowledged the findings.

C 282- OAR 411-054-0045 RN Delegation and Teaching

Actions to be taken to correct the rule violation include:

1. RN will have more training on delegation. RN will now make sure all med staff are trained properly and delegated for insulin injections.  Documentation will reflect staff have been delegated.  Staff will also provide return demonstrations to ensure they can complete the delegated task competently and safely.

2. All current medstaff are retrained in their delegated tasks and have been delegated by RN with appropriate documentation.

3.RN will have system in place to check on staff weekly proforming delegated tasks, then monthly to continue appropriate observation.

4. All new medstaff will be trained and delegated by RN before they are allowed administer any medications, or work in the medroom.  This includes 1:1 training with the RN and return demonstrations for safety and ensuring competency.

RN and Director will monitor.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 3 sampled residents (# 2) who received outside provider services. Findings include, but are not limited to:

Resident 2 was admitted to the facility 12/2020 with diagnoses including Parkinson's disease.

During the acuity interview on 07/10/23, the resident was identified to receive outside provider services.

A review of outside provider documentation from 03/24/23 through 05/10/23, and TSPs (Temporary service plans), revealed the following home health recommendations lacked evidence they were communicated to staff and the plan of care updated:

* 03/24/23: "New ulcer..." to right lower abdominal. Cleanse with wound cleanser, pat dry with gauze, apply Mupirocin [antibiotic ointment] to the area and dressing change daily";

* 04/26/23: Walk with the resident up to three times weekly between breakfast and lunch, using a 4-wheeled walker; and

* 05/10/23: Continue with daily walking using a 4-wheeled walker.

During an interview with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 10:20 am, the surveyor shared there were no current outside provider visit notes after 05/10/23. Staff 2 stated she was not aware that the outside provider service was discontinued. Current visit notes were requested, but no additional documentation was provided prior to exit.

On 07/12/23, the surveyor reviewed the outside provider recommendations and discussed on-going coordination of care for the outside provider services with Staff 1 and Staff 2. They acknowledged the findings.

C 290- OAR 411-054-0045(2) Res Hlth Srvc: On-and off-site Health Service

1. Staff to ensure that all outside agences fill out the Outside Agency form that is located at the med room. Outside agency; PT,OT,Hospice, etc. After they document their visit med staff are to also document on the visit; What it was for? Any new Changes/Follow ups, etc.

2.Outside agency forms will stay in a binder in a section for the resident until resolved. This is to keep it from being misplaced. When finished with outside service, all documentation will be pulled out of binder and put into their file.

3. Review available forms and processes with with 3rd party providers.  This includes:

o3rd Party agency forms will be available for agencies to use.

oEnsuring systems are in place to review all documentation left by agency and by all staff at each shift.  Make sure documentation gets uploaded to PCC if necessary and any changes take place to orders, etcs.

o     Train staff to enter in chart notes, after visit with agency before they leave.  This will confirm 1:1 interaction with community staff and agency staff, before they leave the building.

Director and RN will follow up to make sure forms are available.

RN and Director will watch for any changes.

Based on observation, interview and record review, it was determined the facility failed to coordinate off-site health services for residents who cannot or choose not to self-manage their health services including making adjustments to the resident's services and service plans for 2 of 3 sampled residents (#s 5 and 6) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and acute kidney failure. Resident 5 was dependent on renal dialysis.  

The resident's clinical records, including the service plan dated 03/27/24, progress notes from 02/11/24 through 05/17/24, and outside provider notes were reviewed and revealed a home health communication form completed on 05/15/24 by PT following an assessment related to right knee pain. The communication instructed facility staff to have the resident exercise twice a day.

There was no documented evidence the recommendation was communicated with facility staff in an effort to adjust the resident's services or service plan.

During the interview with Resident 5 on 05/23/24 at 1:40 pm, s/he was unable to recall exercising twice a day per PT recommendation. There was no documented evidence facility staff had updated the resident's service plan to address the PT's recommendation.

The need to ensure the facility coordinated off-site health services for residents who cannot or choose not to self-manage their health services including making adjustments to the resident's services and service plans was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 01/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident was discharged from hospice on 05/20/24.

The resident's clinical records, including the service plan dated 04/03/24, progress notes from 02/09/24 through 05/02/24, and outside provider notes were reviewed and revealed Resident 5 went to the emergency room on 02/08/24 and 02/14/24.

There was no documented evidence the facility staff updated the resident's service plan to incorporate post-visit recommendations including activity restrictions and follow-up instructions.

The need to ensure the facility coordinated off-site health services for residents who cannot or choose not to self-manage their health services including making adjustments to the resident's services and service plans was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

1.RN will check Outside provider binder weekly to review in facility visits to monitor the progress of resident. Med staff are to document on the outside provider form immidiately after visit from outside provider. RN will make a prog note once a week on the visits from outside providers.

2.Daily checks in's with med staff to make sure they are making a prog note of outsider visits with providers. Med staff have been trained on how to chart and what to chart on these visits

3.RCC and RN check daily to ensure outsider visits are documented that day and correctly.

4.RCC reminds med staff daily and will help with adding in provider visits as a 2 step verification

2. Resident 2 was admitted to the facility in 12/2020 with diagnoses including Parkinson's disease.

Resident 2's 07/01/23 through 07/10/23 MARs were reviewed during the survey and were found to be lacking accurate documentation in the following area:

* The MAR showed the scheduled Clobetasol cream was administered by the resident. Interview with the resident and staff during the survey indicated the cream was administered by staff.

The need to ensure the resident's MARs were accurate and included correct documentation was discussed with Staff 1 (Administrator) on 07/12/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and included resident-specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 1 and 2) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 08/2019 with diagnoses including cognitive communication deficit, dysphagia, and abnormalities of gait and mobility.

Resident 1's MARs from 07/01/23 through 07/10/23 and physician orders were reviewed, and revealed the following:

The following PRN medications lacked resident-specific parameters including sequential order of use:

* Acetaminophen 325mg (for pain);

* Hydrocodone/APAP 5-325mg (for pain);

* Bisacodyl 10mg suppository (for bowel care);

* Milk of Magnesia 400mg/5ml (for bowel care);

* Miralax Powder (for bowel care);

* Senna/Docusate 8.6-50mg (for bowel care); and

* Sodium Phosphate enema (for bowel care).

The need to ensure MARs were accurate and provided resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 07/12/23 at 11:00 am. They acknowledged the findings. No further information was provided.

C- 310 OAR 411-054-0055 (2) Medication Administration

Actions to be taken to correct the rule violation include:

1. All PRN medications now have parameters, sequential order of use, and non pharmlogical interventions in place, prior to administering medication.

2. RN will make sure MARS are accurate and up to-date. With daily checks to make sure MARS are correct.

3. All current MARs have been reviewed and updated by RN.

4. Retraining in EMAR system has been scheduled and it will included but not be limited to.

oRN will review resident baselines and parameters in the EMAR system.  

oWill make sure on checklist to review baselines and parameters at each evaluation and service plan update.

         Use of audit tools in EMAR and PCC, that will show RN and Director errors in the EMAR and any missing information.  These audit tools will be scheduled to use regularly if not daily.

Check daily

RN will monitor EMAR daily to make sure all meds are given correctly.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs included resident-specific parameters and instructions for PRN medications and were kept for all medications ordered by a legally recognized prescriber and administered by the facility for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including type 2 diabetes mellitus, chronic diastolic (congestive) heart failure, and acute kidney failure. Resident 5 was dependent on renal dialysis.

The following PRN medication lacked resident-specific parameters for use:

* Epinephrine 0.3mg/0.3ml pen (for severe allergy).

The need to ensure the MAR was accurate and included resident-specific parameters and instructions for PRN medications was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

2. Resident 6 was admitted to the facility in 01/2022 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident was discharged from hospice on 05/20/24.

Resident 6's room had several oxygen tanks and equipment stored, and a progress note dated 05/02/24 stated "Vitals noted SaO2 [oxygen saturation] was only 91%, oxygen was placed on." However, there was no order for oxygen documented on the MAR or noted in the physician orders signed 03/15/24.  During the interview on 05/24/24, Resident 6 indicated s/he was not using oxygen, and Staff 24 (MT) confirmed "S/he used oxygen when really sick on hospice."

The need to ensure residents' MARs were kept for all medications ordered by a legally recognized prescriber and administered by the facility was reviewed with Staff 1 (Administrator), Staff 2 (RN), and Staff 17 (RCC) on 05/24/24. They acknowledged the findings. No further information was provided.

1.RN will update EMAR's for EpiPen, NarCan and of O2 Criteria. Rn will add detailed instructions to med staff on how to/when to administer EpiPen/Narcan in an emergency situation. as well as training on how to administer EpiPen. Oxygen will now be in the orders of making sure O2 is set on the right liter, changing tubing, mantaince of machine if necessary and where and when to order O2 and supplies.

2.RN will train all staff so everyone would be able to help out in an emergency situation.

3.Training will be done as needed and will be part of the hiring process.

4.Nurse

Based on interview and record review, it was determined the facility failed to use the results of an acuity-based staffing tool (ABST) to develop and routinely update the facility's staffing plan and to address all evaluated care needs of residents, including the amount of staff time needed to provide care, in the facility's ABST for 4 of 4 sampled residents (#s 4, 5, 6, and 7) whose ABST inputs were reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed and discussed with Staff 1 (Administrator) on 05/23/24 and 05/24/24.

Review of the sampled residents' ABST inputs revealed multiple ADLs were not reflective of the residents' evaluated care needs. Additionally, the facility's staffing plan was not updated periodically to reflect the necessary staffing hours output from the facility ABST. During the interview on 05/24/24, Staff 1 acknowledged the facility did not update the staffing plan to reflect the care hours calculated by the facility's ABST.

The need to ensure the facility's ABST addressed all evaluated care needs of residents, including the amount of staff time needed to provide care, was discussed with Staff 1 on 05/24/24. She acknowledged the findings. No further information was provided.

1.RCC and Director went through all service Plans and  acuity based staffing tool to ensure all Acuity Based Staffing match service plan.

2.It is checked quarterly or with a change of condition

3.Service plans and acuity will now be done together quarterly and as needed by ED and RCC.

4.The Director and RCC with be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training in all required topics was completed and documented for 4 of 4 newly hired direct care staff (#s 7, 8, 12 and 15). Findings include, but are not limited to:

Facility training records were reviewed on 07/11/23 with Staff 1 (Administrator).

Staff 7 (MT) hired 06/02/23, Staff 8 (MT) hired 07/19/22, Staff 12 (CG) hired 04/14/23, and Staff 15 (Activities/CG) hired 06/20/23, lacked documented evidence of completing the following required elements of the pre-service orientation and pre-service dementia training:

* Staff 7 and Staff 8 lacked documentation of resident rights and values of CBC care, abuse reporting requirements, infectious disease prevention, fire safety and emergency procedures, and pre-service dementia training in all required areas;

* Staff 12 lacked documentation of resident rights and values of CBC care and infectious disease prevention, and pre-service dementia training in specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and use of person-centered approach; and

* Staff 15 lacked documentation of resident rights and values of CBC care, abuse reporting requirements, infectious disease prevention, fire safety and emergency procedures, and pre-service dementia training in all required areas.

The need for newly hired direct care staff to complete the required pre-service orientation training and dementia training before working with residents was reviewed with Staff 1 on 07/11/23. She acknowledged the findings. No additional information was received.

C 370-OAR 411-054-0070 (3-4)

1. Pre Service orientation done for all staff.

2. Infection Control done by all staff

3. Pre Service Training assigned and completed by all staff.

4. Staff 7,8,and 12 completed Pre Service Training and  Infectious disease.

5. Retraining and process review has been requested and scheduled by home office.  This will include but not be limited to:

oWill go over Relias Training website with Director and RCC.  How to use and tracking staff trainings.

oWill do an audit of staff files and make sure training checklist are in place and being used

oWill show Director and RCC how to use reports in Relias for tracking.

IT Manager will also review computer training station and possible setup an additional computer or location for training in the building so more then one person at a time can do training.  Will also go over with Director how staff can train at home and get paid so they can get caught back up before the deadline.

Director will monitor and make sure all training is complete before staff start on the floor.

Each time someone is hired and monthly training.

The Director will be responsible to make sure all staff are trained correctly.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired direct care staff (#s 7 and 12) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Review of training records with Staff 1 (Administrator) on 07/11/23, identified Staff 7 (MT) and Staff 12 (CG) lacked documented competency demonstrated in the following required areas:

* The role of service plans in providing individualized care;

* Changes associated with normal aging;

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

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

The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 on 07/11/23. She acknowledged the findings. No further documentation was provided.

C 372- OAR 411-054-0070 (6)(9)

Staffing requirements and training: Caregiver Requirements

Actions to be taken to correct the rule violation include:

1. Pre training for all new staff will be completed before they start working the floor. The on the job training packet as well as the Relias training will be done within 30 days of hire date.

2. Regular in-person or group staff trainings will also be scheduled on the calendar and available for staff that have a harder time training on the computer.

Director will monitor to ensure all training is completed and on time.

Every time there is a new hire and monthly for continuing training.

The Director will be responsible to make sure they are all up to date.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 long-term staff (#s 11 and 16) completed a minimum of 12 hours of annual training related to provision of care for persons in a community-based care setting, including six hours of annual in-service training on dementia care. Findings include, but are not limited to:

Facility training records reviewed on 07/11/23 with Staff 1 (Administrator) identified the following:

* Staff 11 (CG) hired 11/23/21, lacked documentation of a minimum of 12 hours of annual in-service training on topics related to provision of care and chronic disease in the Community Based Care population.

* Staff 16 (CG) hired 11/19/07, lacked documentation of a minimum of 12 hours of annual in-service training on topics related to provision of care and chronic disease in the Community Based Care population, including six hours of annual training on dementia care.

The need to ensure long-term direct care staff received a minimum of 12 hours of annual training was discussed with Staff 1 on 07/11/23. She acknowledged the findings. No further documentation was provided.

C374-OAR 411-054-0070 (5-7) Staff Requirements and Training

Actions to be taken to correct the rule violation include:

1. Director will make sure to be updated on what classes are needed to make state requirements. All staff has been assigned the Infectious Disease Training, through state accredited classes.

2. Annual in-service training is assigned 1 class a month is to be completed. Staff aware of this and will make sure and complete the monthly training. If monthly training is not done, employee will be taken off the schedule until completed.

Director has assigned all staff and must be caught up by 8/22/23 or will be taken off the schedule.

Will continue to monitor monthly so they do not get behind again.

At point of hire or monthly for continued training.

The Director will be responsible to maintain and keep all records.

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 C 260, C 270, C 290 and C 310.

1.Refer to completed POC, C260,C270,

C290, C310, C231, C280,

C361.

2.Make sure all POC are fallowed and cared through.

3.Quarterly

4.Nurse

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 07/10/23 at 12:05 pm, the following was identified:

a. Hallways:

* Handrails throughout the facility were worn and had exposed wood, gouges, and splinters;

* Doors and door frames to resident rooms throughout the facility were worn and damaged; and

* Paint under the door handles to Room 129 and the employee bathroom on the south side of the facility had worn off, exposing raw wood.

b. Laundry room:

* Area around water inlets and outlet for washing machine #2 was rusted and corroded;

* Wall behind washing machine #2 had exposed drywall, black streaks and scratches; and

* Dust accumulated on wall behind dryers.

c. Dining area:

* Paint chipped and underlying structural layer was exposed above mid-wall molding at north and south corners of the facility dining room entrance; and

* Ceiling vent grate was covered with dust.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Administrator) and Staff 4 (Maintenance) on 07/12/23 at 9:40 am. They acknowledged the findings. No further information was provided.

C 613 OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

Actions to be taken to correct the rule violation include:

1. Handrails have now been sanded and restained.

2. Doors and door frames that were wore have been refinished.

3. Door 129 and employee bathroom door has been sanded and restained.

Doors&Walls will now be checked on more regulary and redone as needed.

4. Washer #2 outlet painted.

5. Wall behind washer #2 painted.

6. Dust cleaned behind dryers

7. Walls have been repainted.

8. Ceiling vent cleaned.

Maintence will now check on monthly. Items of concern have been added to the list so it is not forgotten.

Maintenance and Director will watch for any worn wood and dust.

Maintence and Director will do walk through of building monthly.

Director and maintenance