Print Inspection: OMEJ

The findings of the re-licensure survey conducted 01/23/23 through 01/26/23 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

Based on interview and record review, it was determined the facility failed to immediately investigate injuries of unknown cause to rule out abuse or suspected abuse and failed to report the incident to the local Seniors and People with Disabilities (SPD) office if abuse or suspected abuse could not be ruled out for 1 of 1 sampled resident (#3) who experienced an injury of unknown cause. Findings include, but are not limited to:

Resident 3 admitted to the facility in 05/2021 with diagnoses including rheumatoid arthritis.

Interviews with staff and review of Resident 3's clinical records including progress notes, outside service provider notes (hospice), service plans, temporary service plans and evaluations dated 10/22/22 through 01/19/23 revealed the following:

During the acuity interview on 01/23/23, the facility identified Resident 3 had high ADL care needs, was dependent on staff for most ADL care and required use of a mechanical lift and two staff to assist with transfers.

The service plan dated 11/28/22, identified Resident 3 was incontinent of bowel and bladder and required staff to provide total assistance with incontinent care.

In a progress note dated 12/11/22, staff documented a "skin issue Res has bruising in R groin crease. Be cautious not to pull brief too tightly to avoid further bruising."

There was no documented evidence the facility investigated the cause of the bruise or ruled out abuse or suspected abuse and there was no documented evidence the facility reported the incident to the local SPD office.

During an interview on 01/24/23, Staff 1 (ED) stated there was no incident report or investigation documented in Resident 3's record related to the bruise noted on 12/11/22.

The need to ensure injuries of unknown cause were immediately investigated and reported to the local SPD office if abuse or suspected abuse could not be ruled out was discussed with Staff 1, Staff 3 (RCC) and Staff 4 (VP of Management Services) on 01/24/23. They acknowledged the findings and reported the incident to the local SPD office per the survey team's request. The facility provided confirmation of the report prior to exit.

What actions will be taken to correct the rule

violation?

Incident was reported to local APD.

· How will the system be corrected so this violation will

not happen again?

In-service to be held regarding proper procedure for

abuse reporting, incident report completion and

temporary service plan/alert charting.

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes?

The progress notes will be reviewed weekly, Incident

reports each business day, and TSPs each business day.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored?

The RCC and Executive Director will be responsible.

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

The main kitchen in House 1 and the kitchens in Houses 2 and 3 were toured on 01/23/23 and 01/24/23.

1. The following was identified to need cleaning and/or repair:

* In House 1 the dry storage room shelving had peeling paint throughout and a 2" strip of brown debris along all the edges;

* In House 2 the countertops were worn, exposing the undersurface, creating an uncleanable surface;

* In Houses 1 and 3 the black rubber mat in front of the sink had food embedded in multiple areas; and

* In all three houses the paint was chipping off the cabinetry, exposing bare wood and creating an uncleanable surface.

2. The garbage cans in all 3 kitchens were observed to not be covered.

The above areas were discussed with Staff 1 (ED) during a walk-through of the kitchens on 01/26/23. She acknowledged the findings.

What actions will be taken to correct the rule

violation? All areas of concern are being addressed, parts ordered, etc. Maintenance Director working on corrections.

· How will the system be corrected so this violation will

not happen again?

Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored?

The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.    

Based on observation, interview and record review, it was determined the facility failed to ensure residents' short-term changes of condition were monitored consistent with the residents' evaluated needs with weekly progress noted until conditions resolved for 2 of 2 sampled residents (#s 2 and 3) who experienced short-term changes of condition. Findings include but are not limited to:

1. Resident 3 admitted to the facility in 05/2021 with diagnoses including rheumatoid arthritis.

Interviews with staff and review of Resident 3's clinical records including, progress notes, outside service provider notes (hospice), service plans, temporary service plans and evaluations dated 10/22/22 through 01/19/23 revealed the following:

During the acuity interview on 01/23/23, the facility identified Resident 3 had high ADL care needs and was dependent on staff for most ADL care and required use of a mechanical lift and two staff to assist with transfers.

The service plan dated 11/28/22, identified Resident 3 was incontinent of bowel and bladder and required staff to provide total assistance with incontinent care.

The following short-term changes of condition were documented in Resident 3's progress notes:

* On 10/22/22, staff documented "while changing resident, med aide noticed the resident's red raised area on both buttocks had increased in diameter and the top layer of skin on the red area was rubbing off with gentle touch". The med aide cleaned and treated the area with barrier cream. "Med aide continue to monitor.";

* On 12/01/22, staff documented "During the 0500 incontinence check an open sore on [his/her] Sacral dimple was found to be red all around the area and bleeding slightly, no pain currently. Report to the Med Tech the following: Watch for more redness, swelling, pain and bleeding or any signs of infection". The caregiver "cleaned the area and placed barrier cream on the sore.";

* On 12/11/22, staff documented "skin issue Res has bruising in R groin crease. Be cautious not to pull brief too tightly to avoid further bruising."; and

* On 12/13/22, staff documented "Res had been scratching the R groin crease which was red and moist w/ odor. [Resident 3] tore a mole in the area, which caused it to start bleeding. Area no longer bleeding, cleaned and applied barrier cream, res states relief. Keep area clean and dry and apply barrier cream. Document any bleeding or changes."

There was no documented evidence the facility monitored Resident 3's skin conditions and bruise consistent with the resident's evaluated needs or noted weekly progress of the skin conditions and bruise until the conditions resolved.

During an interview on 01/24/23, Staff 5 (MT) stated "all previous skin break down had healed" and staff provided frequent repositioning, frequent incontinent checks, and applied barrier cream with incontinent care to try to prevent skin breakdown.

The need to ensure residents' short-term changes of condition were monitored consistent with the residents' evaluated needs, with weekly progress noted until conditions resolved was discussed with Staff (1 ED), Staff 3 (RCC) and Staff 4 (VP of Management Services) on 01/24/23. They acknowledged the findings.

2. Resident 2 admitted to the facility in 11/2022 with diagnoses including dementia. Review of Resident 2's clinical record revealed the following:

On 12/05/22, Resident 2 experienced an unwitnessed non-injury fall. The facility placed Resident 2 on alert charting and implemented a non-skid mat under a fall mat to minimize further occurrences of falls. A progress note on 12/13/22 indicated Resident 2 sustained a delayed bruise as a result of the fall.

On 01/05/23, a progress note indicated Resident 2 was being removed from alert charting for the fall. There was no documented evidence of weekly progress noted until the condition was determined resolved.

On 01/25/23, the need to ensure resident specific interventions were documented weekly with progress noted until changes of condition were resolved was discussed with Staff 1 (ED). She acknowledged the findings.

What actions will be taken to correct the rule

violation? All TSPs and progress notes reviewed to ensure proper documentation being done. ED/LPN will be making weekly notes on all temporary and significant change of conditions. Staff training provided on TSPs, Incident Reports as well as daily documentation.

· How will the system be corrected so this violation will

not happen again? The Executive Director/LPN will review TSPs and progress notes weekly, as well as ensure that she provides a weekly nursing note on all short term and significant changes of conditions.

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes? Daily review of TSPs and Incident Reports by the RCC and ED, Weekly progress notes review and documentation by the ED.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored? The Executive Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, fire drill records included documentation of all required elements and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Review of fire and life safety records for August 2022 through January 2023 identified the following deficiencies:

1. There was no documented evidence of fire drills conducted every other month.

2. The facility was not relocating residents during fire drills so there was no documentation of location of simulated fire origin, the escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, number of occupants evacuated, and evidence alternate routes were used.

3. There was no documented evidence of fire and life safety instruction provided to staff on alternate months.

These findings were reviewed with Staff 1 (ED) and Staff 9 (Maintenance) on 01/25/23 at 2:45 pm. They acknowledged the need to document all required components on fire drills conducted every other month and implement fire and life safety instruction to staff on alternate months.

What actions will be taken to correct the rule

violation? Fire Drill forms reviewed and Maintenance Director instructed on appropriate documentation as well as instruction on how to evacuate. Fire Safety training done at the all staff meeting.

· How will the system be corrected so this violation will

not happen again? All Fire Drills/Evacuations will be documented. The Maintenance Director will then turn the form into the Executive Director who will determine if all of the required information is there and then sign off if so. If not, the drill will be re-done in the same month.

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes? Drills and Fire Life Safety will be reviewed monthly.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored? The Maintenance Director and Executive Director

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

The interior of the facility was toured on 01/23/23. The following deficiencies were identified:

* The doors throughout Houses 1 and 3 had multiple patches of finish that were worn off;

* Multiple door frames throughout Houses 1 and 3 had scratches and gouges;

* The handrails throughout Houses 1 and 3 had scratched paint; and

* The sliding glass door runner in House 1 had black debris buildup along length of runner.

The areas needing cleaning and/or repair were reviewed with Staff 1 (ED) on 01/26/23. She acknowledged the items needing cleaning or repair and reported the doors and door frames were being repaired soon.

What actions will be taken to correct the rule

violation? All doors in house 1 and 3 will be painted and repaired.

· How will the system be corrected so this violation will

not happen again?

Regular walk throughs will be performed to observe environmental concerns by the Maintenance Director as well as the Executive Director

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes? Maintenance Director will review each working day and report to Executive Director. Both the Maintenance Director and Executive Director will do weekly walk throughs together.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored?

The Executive Director will ensure walk throughs are occurring and areas needing addressed are taken care of.    

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes to alert staff when residents exit the RCF and failed to provide a functional call system that connected resident units to the care staff. Findings include, but are not limited to:

1. The interior of the facility was toured on 01/23/23.

House 1, an unsecured RCF building, had five exit doors through which residents could exit. Houses 2 and 3, secured MCC buildings, each had two exit doors through which residents could exit the building into secured outdoor areas. When the surveyor exited through these doors, no audible alert was heard.

In an interview on 01/24/23, Staff 9 (Maintenance) confirmed there was no system that alerted staff when a resident exited any of the doors. On 01/25/23 Staff 9 was observed installing alarms in Building 3 and reported that alarms for the other two buildings had been ordered.

2. In a group interview on 01/25/23 an unsampled resident reported that his call light "works on and off". The resident's call light was tested and rang the first time but did not work the following four times. Staff 9 unplugged the cord and plugged it back in and the alarm worked on the following five tests. A repair log showed the call light had been repaired on 05/03/22. In an interview 01/25/23 Staff 9 stated the resident had not reported the repair as ineffective. On 01/26/23 Staff 1 (ED) reported she had called an electrician to repair the call light and that she would implement a quality control test log for the call light system.

During a walk-through of the environment on 01/26/23, these finding were reviewed with Staff 1. She acknowledged the findings.

What actions will be taken to correct the rule

violation? Door chimes installed on all exit doors, Call lights will be tested regularly.

· How will the system be corrected so this violation will

not happen again? Maintenance Director will test all door chimes to ensure that they are working monthly, each call light will be tested monthly as well and data kept on a log.

· How often will the area needing correction be

evaluated and who is assigned to evaluating the

changes? All chimes and call lights will be checked monthly.

· Who on your staff will be responsible to see that all

the corrections are completed and monitored? The Maintenance Director and Executive Director

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C231, C240, C420, C513 and C555.

Refer to POC for: C 231, C 240, C 420, C 513, and C 555

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 10, 11 and 12) completed all required pre-service orientation training prior to beginning their job responsibilities, and 3 of 3 long-term staff (#s 5, 13 and 14) completed a minimum of 16 hours of in-service training annually. Findings include, but are not limited to:

Training records were reviewed on 01/25/23 with Staff 15 (Business Office Manager). The following deficiencies were identified:

a. There was no documented evidence Staff 10 (CG), Staff 11 (CG), or Staff 12 (CG), hired 12/20/22, 12/05/22, and 11/14/22, respectively, completed approved infectious disease prevention training prior to beginning their job responsibilities.

b. Staff 5 (MT), hired 02/28/19, Staff 13 (CG), hired 11/01/10, and Staff 14 (CG), hired 05/17/19, failed to complete 16 hours of annual in-service training during hire date intervals of 02/28/21-02/28/22, 11/01/21-11/01/22, and 05/17/21-05/17/22, respectively.

The need to ensure newly-hired staff completed all required orientation training prior to beginning any job duties, and long-term direct care staff completed 16 hours of annual in-service training, which included six hours of dementia care training, was reviewed with Staff 15 on 01/25/23 and Staff 1 (ED) on 01/26/23. They acknowledged the findings.

What actions will be taken to correct the rule violation?

Letters sent out to individuals needing training with the policy and annual training requirments per OAR's, and all employees training will be completed.  

· How will the system be corrected so this violation will

not happen again? New staff will not be permitted to work the floor until all pre-service trainings are complete. Training Completion Spreadsheet will be reviewed prior to scheduling any new staff. Training spreadsheet will be reviewed each month to ensure monthly trainings are being completed and a total of 16 hours of training will be done annually.

· How often will the area needing correction be

evaluated and who is responsible for the evaluation?

RCC will review the staff training spreadsheet prior to

scheduling any new staff. The BOM will enter dates of

training completion into the spreadsheet and alert RCC of those staff members who have not completed the monthly training.

· Who on your staff will be responsible to see that all

corrections are completed/monitored? The RCC and Executive Director

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C270.

Refer to POC for C 270