Print Inspection: NYDE

The findings of the re-licensure survey, conducted 10/03/23 through 10/05/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first revisit to the re-licensure survey of 10/05/23, conducted on 02/28/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second re-visit to the re-licensure survey of 10/05/23, conducted 05/15/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective and provided clear direction regarding the delivery of services for 2 of 6 sampled residents (#s 2 and 5). Findings include, but are not limited to:

1. Resident 5 moved into the facility in 06/2023 with diagnoses including Parkinson's disease and type II diabetes.

Resident 5's service plan, updated 08/08/23, temporary service plans and progress notes dated 07/02/23 through 10/02/23 were reviewed. Interviews with care staff and Resident 5 were conducted and observations were made. The resident's service plan was not reflective or failed to provide clear instruction to staff in the following areas:

* Side rail use;

* Use of an air mattress while in bed;

* Catheter use for bladder elimination; and

* HHRN outside provider services.

The need to ensure service plans were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/04/23. They acknowledged the findings.

2. Resident 2 moved into the facility in 04/2022 with diagnoses including chronic back pain and endometrial cancer.

Resident 2's service plan, last updated 01/27/23, temporary service plans and progress notes dated 06/26/23 through 09/26/23 were reviewed. Interviews with care staff and Resident 2 were conducted and observations were made. The resident's service plan was not completed following a quarterly evaluation and did not reflect the resident's needs or provide clear direction regarding the delivery of services in the following areas:

* Pain, including non-pharmacological interventions and who shall provide the services, what, when, how, and how often the services shall be provided;

* Use of compression stockings;

* Weekly skin checks; and

* Weight monitoring, including daily weights.

The need to ensure service plans were completed quarterly, were reflective of the resident's care needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/05/23. They acknowledged the findings.

Resident #5 care plan updated to reflect clear instruction for catheter care. Care plan updated to include air flow matress, side rail and outside services contact information including anticipated visit plan.

Resident #2 care plan updated to reflect history and current chronic pain, along with pain management plan including pharmacological and non-pharmacological interventions. Coordination of care meeting planned with resident, family and provider addressing resident pain needs. Resident's care plan updated to reflect weekly skin checks, daily weight monitoring and assistance with placing and removing compression stocking by care team.

Review of resident apartment and care plan to be done to assure all aspects of information added to care plan. Review to be done by family and Wellness Director. Review to be done prior to 30 day care review, prior to 90 day review and upon change of condition.

Wellness Director and Resident Services Director will audit and report to Executive. Executive Director to assure compliance.  

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs,  for 1 of 2 sampled residents (# 8) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 8 was admitted to the memory care in 08/2021 with diagnoses including chronic respiratory failure.

Observations, interviews and review of the 01/04/24 service plan revealed Resident 8's service plan was not reflective of the resident's current needs and preferences in the following areas:

* Use of oxygen; and

* Personal companion.

The need to ensure service plans were reflective of residents' current care needs, and preferences were implemented, and provided clear directions to staff was discussed with Staff 1 (ED) and Staff 3 (RN) on 02/28/24

Resident #8 care plan was updated to reflect current needs: including a clear order for oxygen use and instruction for care associates to follow when administering oxgen. Care Plan also updated to introduce private companion and expectations of what companion assists resident with.

Assessment of all residents and walk through of resident apartments with each care plan update to be done to assure all aspects of information added to care plan. Associate training implemented to assure any new equipment brought into resident apartments; such as oxygen is immediately reported to Wellness Director for proper care plan update.

Care plan review to be done by family and Wellness Director. Review of care plan and resident apartment to be done prior to 30 day care review, prior to 90 day review and upon change of condition for all resident.

Wellness Director and Resident Services Director will audit care plan compliance and report to Executive. Executive Director to assure compliance.  

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 1 of 1 sampled resident (# 5) who was being assisted with insulin injections and CBG readings by unlicensed facility staff. Findings include, but are not limited to:

Resident 5 moved into the facility in 06/2023 with diagnoses including type II diabetes.

During the acuity interview on 10/03/23, Resident 5 was identified to be administered insulin injections by non-licensed staff.

1. The resident's 09/01/23 through 10/03/23 MARs and initial delegation records were reviewed and identified the following:

* Staff 6 (Med Tech), Staff 8 (Med Tech) and Staff 10 (Med Tech) documented on the MAR they administered insulin injections to the resident on multiple occasions;

* There was no documentation of how frequently the unlicensed staff should be supervised and reevaluated, including a rationale for the frequency based on the competency of the unlicensed staff, for Staff 6, Staff 8, and Staff 10;

* There was no documentation of how frequently the resident should be reassessed by the registered nurse regarding continued delegation of the task to the unlicensed staff, including rationale for the frequency based on the resident's needs; and

* There was no documentation the Registered Nurse took responsibility for delegating the task to the unlicensed staff and ensured that supervision would occur for as long as the Registered Nurse was supervising the performance of the delegated task.

2. Periodic inspection, supervision and re-evaluation delegation records were reviewed and identified the following:

* There was no nursing assessment of the resident's condition to determine that the resident's condition remained stable and predictable; and

* There was no documentation of observation of the competence of the unlicensed staff  to determine they remained capable and willing to safely perform the delegated task of nursing care.

On 10/04/23, the need to ensure all staff who administered insulin injections or performed delegated, taught tasks were appropriately delegated and supervised in accordance with OSBN Administrative Rules was reviewed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN). They acknowledged the findings.

Resident #5 delegation reviewed, all areas now meet requirements for delegation, education of non-licensed staff and re-delegation. Delegation documentation was updated to show frequency of supervision of unlicensed staff and rationale for frequency of re-delegation; frequency of resident reassessment including rationale for frequency; RN has documented taking responsibility for delegating and supervising unlicensed staff and responsibility for supervision for the duration of the RN supervising; RN assessment of resident condition to determine stability; documented competency of skill of unlicensed staff.

RN to attend Role of the RN course provided by OHCA 12/5-12/7. Complete delegation documentation prior to unlicensed staff administering insulin, including RN assessment of resident for stability and predictability. Re-delegation will be completed per state regulations within 60 days after initial delegation and no later than 180 days for all additional delegations.

RN and WD will eval delegation documentation upon move in, within 60 days of new delegations and quarterly.

Executive Director to review compliance of delegation quarterly with RN. RN, Wellness Director and Executive Director to assure compliance.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:

During the survey, meal observations were made of staff in the dining room. Staff were observed removing dirty dishes, assisting residents with their napkins and utensils, touching residents and serving residents their meals without changing their gloves or performing hand washing.

The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene while serving meals to the residents, was discussed with Staff 1 (ED) and Staff 3 (Resident Services Director, RN) on 10/05/23. The findings were acknowledged.

Associates educated on proper hand hygiene and infection control protocol when serving meals. Additional hand sanitizing stations available in the dining room and prep room for frequent use between hand washing.

Dining Services Director will assure all current staff and new staff are trained in proper infection control when serving and clearing tables/residents.

Dining Services Director and Executive Director will check in quarterly for competency and to identify  correction or additional training needed.

Dining Services Director to assure compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month and documented all required components in accordance with the Oregon Fire Code every and to ensure fire and life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

Review of fire and life safety records for 04/2023 through 09/2023 and an interview with Staff 1 (ED) and Staff 5 (Plant Operations Director) on 10/04/23 revealed the facility lacked documentation of the following:

* Fire and life safety instruction to staff on alternate months; and

* Fire drills conducted and recorded every other month according to the Oregon Fire Code.

On 10/04/23, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1, Staff 3 (Resident Services Director, RN) and Staff 5. They acknowledged the findings.

Plant Operations Director was educated on missing component including location of simulated fire, escape route used, and number of occupants evacuated. Also educated on requirements of documented evidence fire and life safety instruction to be provided to staff on alternate months of fire drills. Every other month drills and education will be completed on alternating months going forward.

Plant Operations Director will complete every other month drills and education will be completed on alternating months ensuring all components are completed and documented. This will be recurring throughout the year.

Every other month drills and education will be completed on alternating months ensuring all components are completed and documented. Executive Director will audit quarterly.

Executive Director and Plant Operations Director to ensure compliance.     

Based on interview and record review, it was determined the facility failed to ensure fire drills  conducted every other month documented all required components in accordance with the Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

Review of fire and life safety records for 01/2024 through 02/2024 and an interview with Staff 1 (ED) and Staff 19 (Plant Operations Director) on 02/28/24 revealed the facility lacked documentation of the following:

Fire drills conducted and recorded every other month lacked the following required elements:

* Escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time needed; and

* Number of occupants evacuated.

On 02/28/24, the need to ensure the facility conducted fire drills every other month, staff received required fire and life safety training, and fire drill documentation included required components according to the Oregon Fire Code was reviewed with Staff 1. She acknowledged the findings.

Plant Operations Director was given proper documentation to use during fire drills to assure all required elements are included; Escape route used, problems encountered, comments relating to residents who resisted or failed to participate in the drills, evacuation time needed, number of occupants evacuated.

Fire drills will be performed on "odd" months and fire life safety education to be reviewed with all staff during "even" months.

Executive Director and Plant Operations Director to assure compliance quarterly and plan upcoming drills and education.      

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 420, C 613, and C 645.

All findings during re-licensure on 2/28/2024 have been addressed and have planned compliance audits in place. Findings included: C 260, C 420, C 613, and C 645. Refer to evidence found in attached POC for correction plan and assurance of ongoing compliance.

Executive Director to audit at least quarterly to assure compliance with C 260, C 240, C 613, and C 645 are ongoing and in place.     

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

Observations of facility pathways around courtyards and seating areas on 10/03/23 at 9:45 am identified the following:

* Multiple drop-offs of two to three inches were noted along pathway edges around the perimeter of outside courtyards and seating areas.

The need to ensure pathways around the facility were in good repair with no potential tripping hazards was discussed with Staff 1 (ED) on 10/04/23 at 11:20 am. She acknowledged the findings.

Pathways, walked and drop-offs filled in AL courtyard and surrounding pathways by Plant Operations Director.

Plant Operations Director will look for areas of opportunity weekly during community walk throughs of the exterior property. Plant Operations Director will fill in any noted areas.

Plant Operations Director and Executive Director will walk exterior quarterly to assure compliance.

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

During a tour of the facility on 10/03/23 at 9:45 am, the following was observed:

* Multiple doors, including Rooms 101, 103, 114, 119, 121, 122, 207, 222, 235, 253 and 257, had scuffs and scratches; and

* Carpet was stained in front of Room 119 and between the dining room and adjacent seating area.

The environment was toured on 10/04/23 at 11:20 am with Staff 1 (ED). She acknowledged the above areas needed to be cleaned and repaired.

All interior doors that needed cleaning and repainting were remedied by Plant Operations Director and team. Carpet with staining cleaned by Plant Operations Director.  

Plant Operations Director will look for areas of opportunity weekly during community walk throughs of the interior property. Plant Operations Director will clean and repair any doors and or areas of opportunity paying special attention to doors with previous areas of concern and resident doors that are independent with mobility devices.

Plant Operations Director and Executive Director will walk interior together monthly assuring that all areas of opportunity are addressed and in compliance.

Plant Operations Director to assure compliance.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

During a tour of the facility on 02/28/24 at 10:30 am, the following was observed:

* Carpet was stained in front of Room 119 and between the dining room and adjacent seating area; and

* Pervasive urine odor in hallway of unit 122.

The environment was toured on 02/28/24 at 01:40 pm with Staff 19 (Plant Operations Director).

The need to ensure the interior of the facility was kept clean and was free of unpleasant odors was discussed with Staff 1 (ED) on 02/28/24. She acknowledged the above areas needed to be cleaned and repaired.

Carpet in front of room 119 and between dining area and nearby seating were cleaned and no longer show visable staining.

Community carpet cleaning placed on planned cleaning rotation at least quarterly and audited monthly  by Executive Director and Plant Operations Director for continued cleanliness and or need for more extensive cleanring.

Pervasive urine odor in hallway of unit 122 addressed with resident and resident POA to assure care plan is meeting needs to reduce/eliminate excessive urine odor. Care conference with POA scheduled to discuss need for additional care. Weekly audits in place to assure resident compliance with care. Odor elminating device in place near hallway of unit 122 to address any residual odor.

Executive Director, Plant Operations Director and Wellness Director to assure compliance with weekly audits for lingering odor.  

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. Findings include, but are not limited to:

On 10/03/23, the surveyor measured water temperatures in six resident units. The water temperature ranged from 94.2 degrees to 104.6 degrees Fahrenheit. Staff 11 (Plant Ops Associate) was present for testing of the water temperatures.

In an interview on 10/04/23 at 11:45 am, Staff 1 (ED) confirmed the facility was aware of the water temperature issue and was continuing to work with their vendor to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit.

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 on 10/04/23. She acknowledged the facility needed to implement a system for monitoring water temperatures.

Water temperatures will be adjusted to ensure they are within the range of 110-120 degrees. We are currently continuing to work on this with our outside vendors.

Housekeepers to check room temps weekly on scheduled housekeeping days. Housekeeper will complete and return to Plant Operations Director who will report fininds to Executive Director Monthly.

Plant operations director will audit findings weekly and correct and address discrepancies with Executive Director. Plant Operations Director will also report monthly to executive director.

Plant Operations Director will ensure compliance.

Based on observation and interview, it was determined the facility failed to ensure water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit. This is a repeat citation. Findings include, but are not limited to:

On 02/28/24, the surveyor measured water temperatures in five resident units. The water temperature ranged from 99.1 degrees to 125.7 degrees Fahrenheit.

In an interview on 02/28/24 at 2:00 pm, Staff 1 (ED) confirmed the facility was aware of the water temperature issue and was continuing to work with their vendor to adjust the water temperatures to be within the range of 110 and 120 degrees Fahrenheit.

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 and Staff 19 (Plant Operations Director) on 02/28/24. They acknowledged the findings.

Recirculation pump replacement initiated on 3/12/2024. Water temperatures will be adjusted to ensure they are within the range of 110-120 degrees.

All associates educated on importance of proper water temperatures and reporting concerns for potential out of temperature range to Plant Operations Director who will address and report out of compliance areas to Executive Director Monthly.

Plant Operations Director will audit random resident apartments throughout the community weekly to assure temperature proper range, correct and address discrepancies with Executive Director.

Plant Operations Director will ensure compliance.