Print Inspection: OMGL

The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 05/04/22, conducted 11/07/22 through 11/09/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit to the re-licensure survey of 05/04/22, conducted 03/29/23 through 03/30/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 third re-visit to the re-licensure survey of 05/05/22, conducted 07/21/23, 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 licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:

During the re-licensure survey, conducted 05/02/22 through 05/04/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

OR-411-0025 C-150 Facility Operation

1. Please see Plan of Correction in its completeness.

2. Executive Director will meet with each Department on a scheduled weekly meeting with an agenda to review all of the areas of the community.

3. This will be evaluated weekly.

4. Executive Director and Department Heads will meet weekly and discuss QA.

Based on observation, 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:

1. Witness 1 (Ombudsman) shared concerns that residents were dissatisfied with the facility meals and food.

Staff 4 (Dietary Services Manager) documented the following resident comments after meeting with residents about the meals:

* "Meat is tough...";

* "Braised beef tough.";

* "...soups not enough flavor, food not hot..";

* "Beef a little tough.";

* "Beef is tough...no soups have flavor.";

* "A lot of repetition.";

* "Chicken dry...potatoes too hard...hamburger steak no flavor.";

* "...meat is a little tough. Pork and chicken tough...not a fan of the soup."

* "Meats tough or cold, potatoes are tough.";

* "...beef is a little tough...food is a little cold...";

* "...meat is dry...";

* "Some meat is raw and food is cold. Potatoes and vegetables are hard."; and

* "...Pork thin and dry..."

There was no documented follow up to the concerns expressed by the residents.

A test tray of the lunch meal on 05/02/22 was requested and tasted by the Surveyor. The meal was Swiss Steak, cheddar mashed potatoes, and green beans.

The steak was covered with a layer of grease, very difficult to cut, tough to chew, and lacked flavor.

The potatoes were under cooked with hard chunks of potatoes and lacked flavor.

The green beans lacked flavor. They were very soft and fell apart when the surveyor tried to eat them with a fork.

Interviews with residents were conducted on 05/02/22 during the lunch meal. They said:

* "Food sucks.";

* "Doesn't taste good.";

* "Meat is tough.";

* "Swiss steak is tough to eat.";

* "I can't stand to eat it.";

* "Food is OK. We don't have much choice.";

* "The meat was dry. I couldn't cut it.";

* "I couldn't eat meat.";

* "Food is so-so.";

* "The meat is too tough to cut."; and

* "The potatoes have no flavor and are supposed to have cheese. Where is the cheese?"

Interviews with residents were conducted on 05/03/22 during the lunch meal. The meal was BBQ Baby Back ribs, twice baked potatoes, and cream style corn. They said:

* "The food today is not handicap appropriate." The resident requested a staff member cut the rib meat off the bone.;

* "I get the meat pureed but it is still too tough for me to eat.";

* "The baked potato is cold and the meat is hard to chew. This is normal for the meat."; and

* "The meat is cold and the potatoes are dry."

In an interview with Staff 1 (ED) on 05/03/22, she acknowledged she was aware residents had complaints about the food.

2. Witness 1 (Ombudsman) informed the survey team of resident complaints of extended call light response times.

Review of the call light response times between 04/01/22 and 04/30/22 revealed numerous occasions when response times to call lights were greater than 20 minutes, up to over an hour.

During an interview with Staff 1 (ED) she stated residents reported long call light response times to her.

The documented complaints of residents were discussed with Staff 1 (ED) on 05/03/22. She acknowledged there was no documentation regarding follow-up to residents' concerns.

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure

1. ED or designee will meet with dietary services director weekly to discuss food quality. ED or designee will do random test trays before meal service begins.

Staff Inserviced on 5/12/22 for proper call times and answering them in a timley manner.

2. ED will meet with DSD weekly as part of QI. ED or designee will review call light times weekly to ensure timely call times. DSD or designee will hold a monthly food committee meeting with the residents to discuss food likes, dislikes, changes, and special requests.

ED or designee will hold a monthly town hall meeting with the residents to discuss any comments, or concerns.

3. ED will meet with DSD weekly to discuss QA for food quaility and any concerns.

Food quality will be reviewed randomly by different managers throught the month with test trays.

ED and/or RN/RCC will review call light times weekly and will be discussed at weekly QA meeting with ED and RN/RCC.

Town hall and Food Committee meetings with residents scheduled monthly.

4. ED and DSD will review food quality and concerns weekly during Kitchen QA meeting.

ED and RN/RCC will review call light times weekly during Health Servies QA meeting

Based on observation, interview and record review, it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes and resident satisfaction. Findings included, but are not limited to:

During the survey, conducted 05/02/22 through 05/04/22, quality improvement oversight to ensure adequate resident care, services and satisfaction was found to be ineffective.

Refer to the deficiencies in the report.

OR-411-0025 C-156 Facility Quality Improvement

1. Re-establishing the Pacifica Quality Assurance program that was not in use at time of survey.

2.All areas identified in QA Audit will be corrected in a timely manner and/or documentation will be evident of efforts put into place to correct immediately.

3.Audits will be performed according to QA scheduled weekly and discussed with Departent Manager:

* DSD/Kitchen - Diet boards, snack program, cleaning, equipment, food quality, food storage, menu and food ordering, temp logs, ect. Audit sheet will be in completed POC binder.

* RN/RCC Health Services - resident files, assessments/evaluations, PCP reports, Service Plans, COC, outside provider documentation, 24 hr communication binder, Medtech/PCA training, MAR, med cart audit, supplies, shower/laundry schedules, ect. Audit sheet will be in completed POC binder.

* MD/Fire and life safety -building and grounds appearance, housekeeping, fire drills, emergency evacuations, fire extinguishers, ect. Audit sheet will be in completed POC binder.

* BOM/HR - workers comp, personnel files, employee orientation, employee training, background checks, time tender, montly employee safety meetings, dress code, ect. Audit sheet will be in completed POC binder.

4. Executive Director will be reviewing audit sheets with Dept. Managers weekly. If ED see there are areas of immediate concern while completing audit, department manger will be notified right away.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control. Findings include, but are not limited to:

During the survey, conducted 05/02/22 through 05/04/22, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility.

From 05/02/22 through 05/04/22, numerous facility staff were observed wearing face masks below their noses or chins on multiple occasions.

The failure to ensure facility staff consistently utilized COVID-19 protocols was discussed with Staff 1 (ED) on 05/02/22 and 05/04/22. She acknowledged the findings.

OAR  411-054-0025 (4) Reasonable Precautions

1. Staff were in-serviced on 5/12/22 about mask use in the community.

2. ED and/or Department Managers, and/ or designee will do daily walks and will check staff to ensure their masks are being worn properly.

3. Daily reminders will be given to all staff who are not wearing their masks properly.

4. ED and/or department managers and/or designee will remind staff to wear their masks properly if staff are not doing so.

Based on observation, interview and record review, it was determined the facility failed to ensure resident evaluations addressed all required elements, were relevant to the needs and current conditions of the resident, and indicated who was involved in the evaluation process for 4 of 5 sampled residents (#s 2, 3, 4 and 5) whose new move-in and quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 4 moved into the facility in 04/2022.

The new move-in evaluation did not indicate who was involved in the evaluation process, and failed to address the following elements:

* List of current diagnoses;

* List of medications and PRN use;

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

* Ability to use call system;

* Transportation;

* Skin condition;

* Nutritional habits;

* List of treatments: type, frequency and level of assistance needed;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Fall risk or history;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Elopement risk or history;

* Smoking, ability to smoke safely; and

* Alcohol and drug use.

The need to ensure move-in evaluations indicated who was involved in the evaluation process and addressed all required elements was discussed with Staff 1 (ED) on 05/03/22. The findings were acknowledged.

2. Resident 3 was admitted to the facility in 2020 with diagnoses including diabetes and a history of skin breakdown.

Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas:

* Customary routines: sleeping and bathing;

* Spiritual, cultural preferences and traditions;

* List of current diagnoses;

* List of medications and PRN use;

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

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

* Cognition, including: Memory, orientation, confusion and decision making abilities;

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

* Transportation;

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

* Skin condition;

* Nutritional habits;

* List of treatments: type, frequency and level of assistance needed;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Elopement risk or history;

* Smoking, ability to smoke safely; and

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

The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 3 was discussed with Staff 1 (ED) on 05/03/22. The findings were acknowledged.

3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Parkinson's and COVID-19 prolonged.

Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas:

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

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

* Skin condition;

* Nutritional habits;

* List of treatments: type, frequency and level of assistance needed;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Recent losses;

* Elopement risk or history;

* Smoking, ability to smoke safely; and

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

The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 2 was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

4. Resident 5 was admitted to the facility in 01/2021 with diagnoses including heart failure and Resident 1 was receiving hospice services.

Observations and interview with the resident, and review of his/her clinical record revealed the quarterly evaluation did not indicate who was involved in the evaluation process, and did not address or was not relevant to the needs/current condition of the resident in the following areas:

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

* Skin condition;

* Nutritional habits; and

* List of treatments: type, frequency and level of assistance needed;

The need to ensure the quarterly evaluation indicated who was involved in the evaluation process and addressed the needs and current condition of Resident 5 was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OR-411-0054-0034 C-252 Resident Move-in and Evalutation General

1. Residents #2,3,4,and 5 will be brought into compliance

2. All service plans and new admit evaluations will be reviewed by the resident, the service plan team and/or family to assure that all of the new residents needs are met as well as the service plan is resident specific and person centered. Service plan will be signed by all involved once completed.

All Service plans and new admits will be completed upon move in and reevaluated after 30 days, then every 90 days after move in. Any change of condition will have interventions updated as needed by the RN.

3. 30/90 day and change of conditions will be reviewed daily/weekly during clinic meetings.

4.ED/RN/RCC will assure service plans are completed, and current with any changes warranted.

3. Resident 4 was admitted to the facility in 04/2022 with diagnoses including insulin dependent diabetes, skin breakdown, a urinary catheter, and a biliary drainage bag.

Observations and interviews with Resident 4 during the survey, and review of the clinical record including the initial service plan, dated 04/05/22, was not reflective of the resident's needs and lacked clear direction regarding the delivery of services in the following areas:

* Where the resident preferred to eat his/her meals;

* Foley catheter;

* Biliary draining bag;

* Use of a commode;

* Use of incontinence products;

* Mobility devices;

* Hospital bed;

* Staff assistance to make bed;

* Edema to bilateral lower legs;

* Glasses;

* Dressing assistance; and

* PT services.

The need to ensure the service plan was reflective of Resident 4's current care needs and provided clear direction to staff was discussed with Staff 1 (ED) on 05/03/22. She acknowledged the findings. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were followed, reflective of residents' needs, provided clear direction to staff, and were updated with resident changes for 3 of 5 sampled residents (#s 2, 4 and 5). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 01/2021 with diagnoses including heart failure and was receiving hospice services.

Observations of the resident, interviews with staff from 05/02/22 to 05/04/22, and review of the service plan, dated 03/02/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and did not provide clear direction to staff in the following areas:

* Meal assistance, cueing and positioning;

* Skin at risk and interventions;

* Falls and safety interventions; and

* Pain.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

2. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Parkinson's and COVID-19 prolonged.

Observations of the resident, interviews with Resident 5 and staff from 05/02/22 to 05/04/22, and review of the service plan, dated 03/03/22, showed the service plan was not reflective of the resident's current care needs, had not been updated, and did not provide clear direction to staff in the following areas:

* Transfer assistance of up to two staff;

* Mobility assistance including wheelchair and walker use;

* Toileting assistance;

* Bathing and grooming assistance; and

* Hospice services being discontinued;

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were updated with changes, was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1. Residents #2, 4, and 5 will be brought into compliance

2. All service plans and new admit evaluations will be reviewed by the resident, the service plan team and/or family to assure that all of the new residents needs are met as well as the service plan is resident specific and person centered. Service plan will be signed by all involved once completed.

All Service plans and new admits will be completed upon move in and reevaluated after 30 days, then every 90 days after move in. Any change of condition will have interventions updated as needed.

3. 30/90 day and change of conditions will be reviewed daily/weekly during clinic meetings.

4.ED/RN/RCC will assure these are completed, current with any changes warranted.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff, and were updated with resident changes for 1 of 3 sampled residents (#9). This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 2002, was receiving hospice services, and had diagnoses including a decubitis ulcer and edema.

Resident 9 was identified to have had a significant decline in condition and went from being independent with care to requiring full assistance with all activities of daily living.

Resident 9 was observed seated in a recliner with his/her legs elevated. Resident 9 reported s/he had recently become increasingly weak and was no longer able to walk.

In an interview with Staff 14 (MT) on 11/09/22, she reported Resident 9 had declined significantly after a fall and now required full assistance with all care. Staff 14 explained Resident 9 preferred to sleep in his/her recliner, had edema and needed his/her legs elevated, and had a bed-side commode available for use. Staff 14 reported Resident 9 was checked on hourly and assisted and encouraged to change positions. Staff 14 said Resident 9's pressure ulcer was not currently open.

Resident 9's service plan was not reflective of:

* Sleeping preferences;

* Elevation of legs;

* Position changes; and

* Hospice services.

The need to ensure service plans provided clear direction to staff, were reflective of resident needs, and updated with changes, was reviewed with Staff 1 (ED) on 11/08/22 and 11/09/22. She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

1. Resident #9 - service plan will be brought into compliance by updating sleeping preferences, elevation of legs, position changes, and hospice services.

2. 30/90 day service plans and change of conditions will be reviewed daily/weekly during QA meetings.

3.ED/RN/RCC will assure these are completed, current with any changes warranted.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5). Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 5's most recent service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plan.

The need to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OR-411-0054-0036 C-262 Service Planning Team

1. All direct care staff will be inserviced on Service Planning and Procedures.

Service Planning Team will consist of the RN/RCC/ED, resident/family/POA, and whomever resident chooses to be involved.

2. Part or all of the Service Planning Team will meet weekly/daily to review upcoming Service Plans that are coming due and discuss any changes or updates to be added.

3. These Service Plans once updated will be reviewed with resident and/or residents choice/family/POA when possible and changes implemented as needed.

4.ED and or Designee, RCC, or RN will audit servic plan during daily clinical and/or weekly QI

Based on observation, interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and monitor the resident consistent with his/her evaluated need for 4 of 6 sampled residents (#s 1, 3, 5 and 6). Findings include, but are not limited to:

1. Resident 3 was admitted in 2020 and had diagnoses which included diabetes.

Resident 3's clinical record and charting notes, reviewed from 04/01/22 through 05/02/22, revealed the following:

a. On 02/01/22, staff reported the resident had a bruise on his/her right thumb. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition.

b. A narrative charting note written by Staff 2 (RN) on 02/02/22, indicated the resident was "going to be put on insulin, and CBGs four times a day with sliding scale." Alert monitoring was initiated the same day. However, there was no on-going monitoring of the resident's significant change in condition consistent with his/her evaluated needs or until it was determined that monitoring was no longer needed.  

Additional information was requested on 05/03/22.

On 05/04/22, Staff 1 (ED) reported she reviewed the resident's record and concluded the short-term change in condition had not been monitored until resolved, and the resident's significant change in condition had not been monitored consistent with his/her evaluated needs. No further information was provided.

2. Resident 6 was admitted in 2016 with diagnoses which included hypertension and COPD.

Resident 6's clinical record and narrative charting notes, reviewed from 02/20/22 through 05/01/22, revealed the following short-term changes in condition:

a. On 02/20/22, the resident was placed on alert monitoring for a medication error. Review of the record revealed no documentation on the progress of the resident's condition at least weekly until resolved.

b. The resident was seen in the hospital on 03/21/22 and was diagnosed with a UTI. S/he returned to the facility the same day. Documentation indicated the facility initiated short-term change monitoring. However, no monitoring until resolution was documented for the change in condition.

Additional documentation was requested on 05/03/22.

In an interview on 05/03/22 at 3:00 pm, Staff 2 (RN) stated she was unable to find documentation that the short-term changes in condition were monitored until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. She acknowledged the findings.

4. Resident 5 was admitted to the facility in 01/2022 with diagnoses including heart failure and was receiving hospice services.

Resident 5 was observed to be in bed and receive all care in bed on all days of the survey.

Staff reported Resident 5 was bed bound and all care, including incontinent care, was provided in bed. Staff explained hospice provided bed baths and nursing oversight.

Hospice communication was reviewed and revealed Resident 5 was identified to be impacted or constipated on:

* 02/07/22 - "...last BM [bowel movement] was 3-4 days ago...";

* 02/14/22 - "Manually disimpacted for very large hard stool...severe constipation."; and

* 4/18/22 - "...last BM reportedly 2 days ago...".

Resident 5 was at risk for constipation. There was no documented evidence of monitoring of Resident 5's bowel movements.

The need to monitor residents per their evaluated needs was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged Resident 5 was not monitored for constipation.

3. Resident 1 was admitted to the facility in 06/2019.

Resident 1's narrative chart notes dated 02/07/22 through 05/02/22 were reviewed and revealed there was no documented evidence the facility monitored the following changes of condition until resolution:

* 02/05/22 Blood in urine;

* 02/07/22 Fall;

* 02/09/22 Bleeding around nephrostomy tube;

* 02/12/22 Went to hospital and received IV antibiotics;

* 02/15/22 Started antibiotics and blood in nephrostomy bag;

* 02/15/22 New antibiotic doxycycline;

* 03/23/22 Flu like symptoms;

* 04/01/22 Non-injury fall;

* 04/09/22 Sent to ER for frank bleeding in nephrostomy bag;

* 04/09/22 Started new antibiotics;

* 04/14/22 Admitted to the hospital for displaced nephrostomy tube;

* 04/18/22 Complaint of right side pain;

* 04/19/22 New confusion;

* 04/27/22 Sent to ER for thick red fluid in nephrostomy bag; and

* 04/28/22 Return from hospital and new prescription.

The need to ensure the facility documented monitoring of short-term changes of condition until resolution was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. RN and RN Consultant will review all residents in the community to ensure all change of conditions are noted and Service Plans updated to reflect changes.

All direct care staff will be in-serviced on change of condition and monitoring as well as how and who to report to once identified.

2. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to discuss next steps, review service plan and make any further changes such as interventions when needed. They will also review chart notes and confirm alert charting is completed daily.

3. ED/RN/RCC will review COC and monitoring daily.

4. ED or Designee, RCC, or RN will review COC and monitoring during daily clinical and weekly QA.

Based on observation, interview, and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and failed monitor residents consistent with their evaluated needs for 3 of 3 sampled residents (#s 7, 8, and 9). This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 02/2019 with diagnoses including insulin dependent diabetes and was evaluated to be at risk for falls.

Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, Outside Agency/Services Documentation, and facility Unusual Incident/Injury report indicated:

* Resident 7 fell on 08/16/22 with bruising to lower back; and

* Resident 7 was identified with a new treatment to the left heel on 08/24/22.

There was no documented evidence Resident 7's fall interventions were evaluated for effectiveness.

There was no documented evidence of monitoring of the bruise from the fall or monitoring of the heel until the condition resolved.

2. Resident 8 was admitted to the facility in 09/2022 and was evaluated to be at risk for falls.

Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, Outside Agency/Services Documentation, and facility Unusual Incident/Injury report indicated:

* Resident 8 fell on 10/03/22, 10/28/22, and 11/04/22; and

* Injuries resulted from the fall on 10/28/22.

There was no documented evidence Resident 8's fall interventions were evaluated with each instance and monitored for effectiveness.

There was no documented evidence of monitoring of the skin tears from the fall on 10/28/22 until they resolved.

3. Resident 9 was admitted to the facility in 06/2002, was receiving hospice services, and was identified as requiring full assistance with all care needs.

On 10/27/22 it was documented in facility Narrative Charting "...scratches on [Resident 9] left leg were discovered today."

There was no documented evidence the scratches were monitored until resolved.

The need to monitor interventions related to falls and to monitor changes in residents' condition at least weekly until resolved was reviewed with Staff 1 (ED) and Staff 2 (RN) on 11/08/22 and 11/09/22. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. RN/RCC and/or ED will review all residents in the community with a change of condition and any falls to ensure proper noting and updates are in the service plans.

2. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to discuss next steps, review service plan and make any further changes as needed. Fall interventions and monitoring of effectivness will be reviewed as well as any related injuries are monitored properly until resolved.

3. ED/RN/RCC will review COC and fall monitoring during working days.

4. ED or Designee, RCC, or RN will review COC and fall monitoring during daily clinical and weekly QA.

Based on interview and record review, it was determined the facility failed to monitor and document on the progress of short-term changes in condition at least weekly until resolved, and failed monitor residents consistent with their evaluated needs for 2 of 4 sampled residents (#s 11 and 13). This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 08/2019 with diagnoses including age related cognitive decline and was evaluated to be at risk for falls.

Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, and facility Unusual Incident/Injury report indicated Resident 11 fell on:

* 01/10/23 and had a swollen left wrist;

* 01/26/23 with no noted injury; and

* 03/17/23 and had "discoloration" to the right arm, "...scrape to left side of chin.." , and "...apparent skin abrasions..."

On 3/22/23 Resident 11 was identified with discoloration on the right hip, attributed to the 03/17/23 fall.

There was no documented evidence Resident 11's fall interventions were evaluated with each instance and monitored consistent with their evaluated needs.

There was no documented evidence of monitoring of the injuries from the falls until they resolved.

2. Resident 13 was admitted to the facility in 07/2018 with diagnoses including cerebral palsy and was evaluated to be at risk for falls.

Review of the resident's evaluation, service plan, temporary service plans, Narrative Charting, and facility Unusual Incident/Injury report indicated:

* Resident 13 was identified with rashes:

-  Underneath both breasts, and left and right hips on 01/08/23;

-  Left armpit/beneath breast on 03/19/23; and

* Resident 13 fell on 03/05/23 resulting in a knee strain and hematoma to the left leg.

There was no documented evidence Resident 13's fall interventions were evaluated and monitored consistent with evaluated needs.

There was no documented evidence of monitoring of the rashes until they resolved.

The need to monitor interventions related to falls and to monitor changes in residents' conditions at least weekly until resolution was reviewed with Staff 1 (ED) on 03/29/23 and 03/30/23. She acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

1. Daily/Weekly clinical meeting will take place with the RN/RCC/ED to review:

-Incident report packets.

-fall monitoring and updates to TSPs/care plans with any needed addditional fall interventions.

-Alert charting for consistency of charting. The medtechs will be using a "V&A-alert charting log and audit tool".

-Skin logs for as needed assessments by the RN and weekly monitoring from the RN.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by a facility RN for 3 of 3 sampled residents (#s 1, 2 and 3) reviewed for significant changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted in 2020 and had diagnoses which included diabetes and a history of skin breakdown.

During the entrance conference on 05/02/22, Staff 2 (RN) stated the resident had a history of skin breakdown and was a diabetic.

Review of the resident's clinical record revealed the following:

a. On 02/01/22, staff documented in narrative charting notes the resident had open wounds on his/her right leg.

Home health, initiated 02/08/22, indicated the resident "needs care for 4 venous stasis ulcers to left lower extremity."     

The leg ulcers constituted a significant change in condition for which an assessment by the facility RN was required.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 05/03/22 at 9:25 am, Staff 2 (RN) reviewed the record and acknowledged she did not document an assessment of the wounds.

b. A narrative charting note written by Staff 2 (RN) on 02/02/22, indicated the resident was "going to be put on insulin, and CBGs four times a day with sliding scale." This was considered a significant change of condition and required a facility RN assessment.

There was no documented evidence the facility RN conducted an assessment.

During an interview on 05/03/22, Staff 2 (RN) acknowledged the initiation of insulin constituted a change in condition requiring RN assessment. She reviewed the record and acknowledged she had not completed an RN assessment.

3. Resident 2 was admitted to the facility in 11/2021 with diagnoses including Parkinson's and COVID-19 prolonged.

Interviews with Resident 2 and staff revealed Resident 2 required assistance with all care including two staff for transfers at times.

Resident 2 reported s/he had been independent with with most activities but now required assistance.

Staff reported Resident 2 had declined and now required full assistance with all care and at times two staff were needed for transfers.

Resident 2's service plan indicated s/he was independent with care.

Resident 2 experienced a decline in condition in multiple areas constituting a significant change in condition. There was no documented evidence the facility RN had completed an assessment of Resident 2's decline.

Resident 2's change in condition was reviewed with Staff 2 (RN) on 05/03/22. She acknowledged the decline and reported she had not documented an assessment.

The lack of an RN assessment of Resident 2's decline in condition was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension.

Resident 1's narrative chart notes dated 02/07/22 through 05/02/22 and Home Health notes revealed the following significant changes of condition:

a. On 02/07/22, Resident 1 fell in his/her room and fractured two ribs on the left side. An interview with Staff 2 (RN) on 05/03/22 revealed she did not think the fall with fracture constituted a significant change of condition and did not do an RN assessment or update the service plan for Resident 1.

b. On 03/31/22, a Home Health LPN left a note documenting a new wound lateral to the Nephrostomy tube measuring 1.2 cm by 1.4 cm on Resident 1's left side. The note stated the LPN notified Staff 2 (RN) of the new wound.

In an interview with Staff 2 on 05/03/22, she said she knew about the wound and stated Home Health provided the wound care. Home Health services were discontinued for Resident 1 and the last note was left on 03/31/22. Staff 2 revealed she did not provide wound care, conduct an RN assessment for the new wound, or update the service plan.

The need to ensure the facility RN performed an assessment, developed interventions based on the condition of the resident, and updated the service plan was discussed with Staff 1 (ED) and Staff 2 on 05/03/22.  They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services

1. RN completed assessment on Resident 1 and addressed dressing changes and updated service plan.

RN completed assessment on Resident 2 and addressed decline, weakness, and needing more assistance.

RN completed assessment on Resident 3 and addressed insulin, blood sugar, and skin assessment.

2. RN and RN Consultant will review all residents in the community to ensure all change of conditions are noted and Service Plans updated to reflect changes.

3. Change of condition and weight monitoring will be added to the clinical meeting held weekly by the RN and the RCC.

4. ED and/or designee will complete monthly QA audits and review change of conditions, service plans, and end of shift reports, medication reviews, and high risk concerns. If any areas of concern are found the RN will provide assessments and proper monitoring.

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 3 and 4) 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.

During the acuity interview on 05/02/22, Residents 3 and 4 were identified to be administered insulin injections by non-licensed staff.

a. Resident 3's MARs, reviewed from 04/01/22- 05/02/22, revealed insulin had been given by Staff 5, Staff 13 and Staff 14 (MTs) on multiple occasions.

Delegation documentation, reviewed on 05/02/22 revealed no documentation had been completed for Staff 5, 13 and 14.

b. Resident 4's MARs, reviewed from 04/01/22 through 05/02/22, revealed insulin had been given by Staff 7, 14 and 15 (MTs) on multiple occasions.

Delegation documentation, reviewed on 05/02/22 revealed no documentation had been completed for Staff 7, 14 and 15.

In an interview on 05/02/22 at 4:20 pm, Staff 2 (RN) acknowledged she had not performed delegations for Staff 5, 7, 13, 14 and 15. The RN Surveyor informed Staff 2 that unlicensed staff could not give insulin to Residents 3 and 4 without current delegation. She acknowledged and stated that either she or delegated staff would give insulin injections moving forward.

On 05/03/22 at 9:40 am, the RN Surveyor asked Staff 2 who gave insulin to Resident's 3 and 4 that morning. She acknowledged that non-delegated staff performed the injections. The surveyor informed her that unlicensed staff could not perform insulin injections without being delegated. She agreed to immediately delegate unlicensed staff.   

Failure to ensure delegation was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules was reviewed with Staff 1 (ED) on 05/03/22 at 1:20 pm. She acknowledged the findings.

OAR 411-054-0045(1)(f)(B) RN Delegation and Teaching

1. All delegations will be updated. All medtech's will be delegated on Residents 3 & 4.

2. RN will teach and delegate all new med techs on each resident that have blood sugars and insulin.

All delegated med techs will have documentation on each residents.

3. All delegations will be updated if needed with change of order. After initial delegation, Medtechs will be reviewed after 60 days then every 180 days.

4. ED and/or designee will audit delegation records to ensure compliance.  

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight. Findings include, but are not limited to:

During the relicensure survey, conducted 05/02/22 through 05/04/22, the facility failed to ensure a safe medication and treatment system, and administrative oversight was found to be ineffective based on deficiencies in the following areas:

C 282: RN Delegation and Teaching;

C 303: Systems: Medication and Treatment Orders;

C 304: Systems: Medication and Treatment Review;

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration; and

C 372: Training within 30 days: Direct Care Staff.

Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed during the exit meeting on 05/04/22.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments

1. Re-establishing the Pacifica Quality Assurance program that was not in use at time of survey.

QMAR system was updated to show all correct information on the MAR.

All medtechs will be inserviced on Systems: Medication and treatment orders, treatment review, resident right to refuse, medication administration and 90 day orders.

2.All areas identified in QA Audit will be corrected in a timely manner and/or documentation will be evident of efforts put into place to correct immediately.

3.Audits will be performed according to QA scheduled as follows:

* Health Services will be audited weekly, daily clinical

* Staff Training will be reviewed weekly during BOM/HR QA

4. Executive Director will be reviewing with Dept. Managers daily/weekly

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed, and signed provider orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 3 of 6 sampled residents (#s 1, 3 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted in 2020 with diagnoses which included diabetes.

Resident 3's physician orders and MARs, reviewed from 04/01/22 through 05/01/22, revealed the following orders were not followed:

a. Resident 3 had an order for Admelog sliding scale insulin to be given before breakfast, lunch, dinner and bedtime in varied amounts based on results of the CBGs. From 04/01/22 - 05/01/22, there were 63 occasions when the resident should have received the Admelog sliding scale insulin based on CBG results, but none was documented as given.

In an interview on 05/03/22 at 9:00 am, Staff 2 (RN) reviewed the MAR. She was unable to verify if staff had administered the insulin as ordered.

b. The resident had an order for Steglatro (medication for glucose control) 5 mg one tablet once a day. According to the MAR, the resident did not receive the medication from 04/01/22 through 04/05/22 because it was unavailable. Additionally, the PCP had not been notified that the resident did not receive the medication as ordered.

In an interview on 05/03/22, Staff 2 (RN) reviewed the MAR. She acknowledged the medication had not been given as ordered. She also stated staff should have notified the PCP.

The need to ensure orders were followed was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. The findings were acknowledged.

2. Resident 4 was admitted in 04/2022 and had diagnoses which included diabetes, depression, and hypertension.

Resident 4's physician orders and MARs, reviewed from 04/01/22 through 05/01/22, revealed the following orders were not followed:

a. The resident had an order for Lispro sliding scale insulin to be given before meals and bedtime in varied amounts based on results of the CBGs. From 04/06/22 - 05/02/22, there were numerous occasions that staff gave sliding scale insulin without documentation that CBGs were obtained to determine the required amount of insulin to administer.

b. Resident 4 had an order for Bupropion HCL 75 mg 1 tablet every eight hours for depression. According to the MAR, staff failed to administer the medication on two occasions because it was unavailable.

c. The resident had an order for Metoprolol 50 mg two tablets daily at bedtime. Staff were instructed to hold the medication if the BP was less than 100/60 or pulse was less than 60. According to the MAR, staff administered the medication without obtaining the BP or pulse to determine if the medication should have been held.

The need to ensure orders were followed was reviewed with Staff 1 (ED) on 05/03/22 at 1:30 pm. She reviewed the MAR and acknowledged the findings.

3. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension.

Resident 1's 04/01/22 through 04/30/22 MAR was reviewed, and the following deficiencies were identified:

There were no written, signed orders in the facility for any medications or treatments the facility was responsible for administering.

Signed physician's orders for Resident 1 were received from the pharmacy on 05/04/22.

The need to ensure signed physician's orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0055(1)(f-h) Systems: Treatment Orders

NOTES:

1. Residents #3 and 4 - QMar has been updated to show proper information. PCP was notified of missed medications. Resident #1 - signed 90 day orders were completed and in the community by 5/6/2022.

2. Medtechs will be in-serviced on proper QMAR documentation and PCP notification protocols. All 90 Day orders will be completed and signed and in the community. RCC has sent out requests to all residents PCP to ask if we can notify PCP monthly instead of daily for missed and/or refused medications.

3. MARs will be audited weekly by RN and/or RCC

4. ED will audit weekly with QA audit and discuss with RN/RCC during Health Services weekly QA meeting.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment recommendations made by the registered pharmacist were reviewed or implemented. Findings include, but are not limited to:

On 05/03/22, the facility provided copies of pharmacist medication reviews completed on 03/28/22 for numerous residents. The pharmacist requested further clarifications and/or made recommendations.

As of the survey, there was no documented evidence the facility had reviewed and/or notified the residents' prescriber of the pharmacist recommendations.

The failure to follow up on pharmacy recommendations was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. During the interview they acknowledged the facility failed to submit the recommendations to the prescriber for clarification and/or implementation. No further information was provided.

OAR 411-054-0055 (1)(i) Systems: Medication and Treatment Review

1. Pharmacy review on March 28, 2022 - All recommendations sent to MD's for clarification and/or implementation. All reviews for the RN have been addressed.

2. Pharmacy reviews are completed every 90 days and will have all recommendations sent to MD's for clarification and/or implementation. All reviews for the RN will be addressed in a timely manner.

3. Pharmacy reviews are received by OMNI Pharmacy every 90 days and will be reviewed/completed in a timely manner.

4. ED and/or designee, RN will ensure audits are completed /reviewed monthly to ensure compliance.

2. Resident 3 was admitted in 2020.

Resident 3's MARs were reviewed for the time period of 04/01/22 through 05/02/22.

Staff documented Resident 3 refused:

* Ketoconazole 2% Cream (treats fungal infections) on 14 occasions.

There was no documented evidence the facility notified Resident 3's physician of the refusals.

In an interview on 05/03/22 at 9:40 am, Staff 2 (RN) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided.

3. Resident 4 was admitted in 04/2022.

Resident 4's MARs were reviewed for the time period of 04/01/22 through 05/02/22.

Staff documented Resident 4 refused the following medications:

* Clearlax powder (for bowel care) on 17 occasions.

There was no documented evidence the facility notified Resident 4's physician of the refusals.

In an interview on 05/03/22 at 9:40 am, Staff 2 (RN) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 3 of 4 sampled residents (#s 1, 3 and 4) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of hypertension.

Resident 1's April 2022 MARs were reviewed.

Staff documented Resident 1 refused the following medications:

* Amiodarone CHL 100 mg (for heart rate);

* Atorvastatin 10 mg (for cholesterol);

* Doxycycline hyclate 100 mg (for UTI);

* Ferrous sulfate 325 mg (supplement);

* Levothyroxine 50 mcg (for hypothyroidism);

* Lidocaine 5% patch (for pain);

* Methanamine Hipp 1 mg (for UTI prevention);

* Metoprolol succ er 25 mg (for high blood pressure);

* Sensi-care protect oint 113 gm (skin integrity);

* Vitamin C 500 mg to improve effectiveness of methanamine;

* Xarelto 20 mg (for blood clot prevention); and

* Zeasorb prevention powder.

In an interview with Staff 2 (RN) she revealed there was no documented evidence the facility notified Resident 1's physician of the medication refusals for the month of April.

The need to ensure the facility notify the physician/practitioner when a resident refused to consent to orders was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse

1. PCPs for residents #1,3,and 4 were notified of medication refusals.

2.Faxes were sent to all resident MDs to ask about frequency of notifications for medications. Once monthly notifications or continue with notifications for every missed/refused medication. Responses from MD's will be documented and filed in a quick refrence binder.

3. When a new resident moves into the community their MD will be asked for frequency notifications. MDs will be notified if there is a significant change in a residents medications.

4. ED or designee, RN and/or RCC will review every 90 days in corrolation with 90 day physicians orders.  

3. Resident 3 was admitted in 2020 with diagnoses which included diabetes and hypertension.

Residents 3's MARs were reviewed from 04/01/22 through 05/02/22 and the following was noted:

* Reasons for use was not indicated for all medications.

On 05/04/22, the need for the facility to ensure MARs were accurate was discussed with Staff 1 (ED). She acknowledged the findings. No further information was provided.

4. Resident 4 was admitted to the facility in 04/2022 with diagnoses which included diabetes.

Residents 4's MARs were reviewed from 04/01/22 through 05/02/22 and the following was noted:

* Reasons for use was not indicated for all medications.

In an interview on 05/03/22 Staff 1 (ED) reviewed the resident's MAR. She acknowledged several medications were lacking reasons for use. No further information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' MARs were complete, accurate, and provided clear instruction and parameters for administration of PRN medications for 4 of 5 sampled residents (#s 1, 3, 4 and 5) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2021 with diagnoses including heart failure, was bed bound, and was receiving hospice services.

The resident's 03/01/22 through 05/02/22 MARs and physician's orders were reviewed.

a. Resident 5 had a prescription for Magnesium Citrate oral solution 5 oz by mouth if fleet suppository was ineffective after 24 hours.

The Magnesium Citrate solution was entered on the MAR as a daily routine medication to be administered at 8:00 am.  

The medication was documented as refused daily in March 2022.

Resident 5 was noted "physically unable to take" the medication on 04/01/22. The medication was documented as administered on 04/02 through 04/04/22, and as refused on 04/05 and 04/06/22. The medication was discontinued on 04/06/22.

The physician's order and MARs were reviewed with Staff 2 (RN) on 05/03/22. She acknowledged the medication was inaccurately entered on the MAR as a routine medication and the documentation of administration was inaccurate.

b. Resident 5 had physician's orders for:

*Fleet glycerin suppository once daily as needed for constipation; and

*Milk of Magnesia as needed for constipation if no BM in three days.

The were no resident specific parameters directing non-licensed or certified staff on the order of administration of the PRN bowel medications.

The need to ensure MARs were accurate, complete, and included clear direction to staff for medication administration was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/03/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 06/2019 with a diagnosis of Hypertension.

Resident 1's 04/01/22 through 05/02/22 MARs were reviewed and revealed the following medication did not have reasons for use:

* Zeasorb powder;

* Sensi-care protect ointment; and

* Metoprolol succ ER 25 mg tab.

The following PRN bowel medications lacked parameters as to which medication to try first and second:

* Senna 8.6 mg tablet; and

* Polyethylene Glycol 3350 powder.

The need to ensure the facility's MAR has reasons for use for all medications and had parameters for PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/04/22. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

1. RN updated and/or corrected MARS for residents #1,3,4, and 5.

2. RN and/or RCC will review all MARs to ensure they are accurate, complete, and include clear direction to unlicensed staff. RN will also ensure that all PRN medications will have resident specific reason for use and parameters.

3.MARs will be reviewed every 90 days in correlation with 90 day pharmacy reviews as well as when new prescription orders are received.

4. ED will review MARs weekly with RN/RCC during QA meeting.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' MARs were accurate, and provided clear instruction and parameters for administration of PRN medications for 2 of 3 sampled residents (#s 7 and 8) whose MARs were reviewed. This is a repeat ciatation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 02/2019 with diagnoses including insulin dependent diabetes.

Resident 7 had physician's orders for:

* 5 units of Novolog insulin before breakfast and lunch; and

* Novolog insulin on a sliding scale determined by blood sugars before every meal.

Resident 7's 10/01-11/07/22 MARs were reviewed.

The units of insulin administered prior to breakfast and lunch was documented inaccurately on 39 occasions. Staff documented the units given added together for both the routine and the sliding scale orders.

The inaccurate MAR was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 13 (RCC). They acknowledged the documentation was inaccurate.

2. Resident 8 was admitted to the facility in 09/2022 and was receiving hospice services.

Residents 8's 10/01-11/07/22 MARs were reviewed.

Resident 8 had physician's orders for:

* Acetaminophen 325 mg as needed for pain;

* Hydrocodone Acetaminophen 5-325 as needed for pain; and

* Morphine Sulfate 5 mg as needed for pain.

There were no resident specific parameters to guide non-licensed staff which medication to administer and in which order.

The need to provide clear parameters to guide non-licensed staff in the administration of PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN) on 11/08/22 and 11/09/22. They acknowledged the findings.

OAR 411-054-0055 (2) Systems: Medication Administration

1. RN updated and/or corrected MARS for residents #7 and 8.

2. RN and/or RCC will review all MARs to ensure they are accurate, complete, and include clear direction to unlicensed staff. RN will also ensure that all PRN medications will have resident specific reason for use and parameters.

3.MARs will be reviewed every 90 days in correlation with 90 day pharmacy reviews as well as when new prescription orders are received.

4. ED will review MARs weekly with RN/RCC during QA meeting.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 8, 9 and 10) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 05/03/22.

Staff 8 (MT), hired 02/08/22, Staff 9 (CG), hired 03/31/22, and Staff 10 (CG), hired 03/17/22, lacked documented evidence of having completed pre-service dementia training prior to beginning job responsibilities.

Pre-service orientation training documentation provided consisted of completed quizzes with staff names written across the top of the page. There was no documentation of when the quizzes had been completed or staff signatures acknowledging the completion of the pre-service orientation.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts

1. All staff who need training will be completing training immediately either through Relias or inservicing.

2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire. Pre-service orientation and pre-service dementia training will be completed before direct care staff begin their job duties.

BOM will work with RCC/RN to assure all aspects of training is completed

3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance.

4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 caregiving staff (#s 8, 9 and 10) demonstrated satisfactory performance in all required areas within 30 days of hire and were trained in First Aid and abdominal thrust. Findings include, but are not limited to:

Training records were reviewed on 05/03/22.

1. There was no documented evidence Staff 8 (MT), Staff 9 (CG), and 10 (CG), hired 02/08/22, 03/31/22, and 03/17/22 respectively, had demonstrated competency in all required areas within 30 days of hire including, but not limited to:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

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

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

2. There was no documented evidence Staff 8 had demonstrated competence with the administration of medications.

Staff 8's competence with medication pass was observed and documented on 05/03/22.

3. There was no documented evidence Staff 8 had been trained in First Aid.

There was no documented evidence Staff 10 had been trained in First Aid or abdominal thrust.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.  

OAR 411-054-0070 C-372 Training within 30 days: Direct Care Staff

1. All staff who need training will be completing training immediately either through Relias and/or inservicing. All required staff will also be completing online courses for Food Handlers Certification, and CPR/First Aid Certifications.

2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire.

3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance.

4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to have documented evidence the 12 hours of annual in-service training included six hours related to the care of residents with dementia, for 2 of 2 long-term staff (#s 5 and 11) whose training records were reviewed. Findings include, but are not limited to:

The annual in-service training records for the Year 2021 were reviewed on 05/03/22.

Staff 5 (MT), hired 11/19/09, and Staff 11 (MT), hired 09/25/19, failed to have documented evidence of completing six hours of annual in-service training on dementia care in 2021.

There need to ensure staff completed 12 hours of on-going training, including six hours related to dementia, was reviewed with Staff 1 (ED) on 05/03/22. She acknowledged the findings.

OAR 411-054-0070 (5-7) Annual Training and Other Requirements

1. All staff who need training will be completing training immediately either through Relias or inservicing.

2. ED or designee, and/or BOM will assure that all required trainings are completed within 30 days of hire.

BOM will work with RCC/RN to assure all aspects are completed.There will be 12 hours of annual training for staff. Twelve hours in total. Six of the twelve hours will be Dementia training for the direct care staff through Relias. BOM will work with RCC/RN to assure all aspects of training is completed.

3. ED or designee and/or BOM will audit training monthly to assure all training is completed and in compliance.

4. ED and BOM will review weekly during QA meeting

Based on interview and record review, it was determined the facility failed to provide life safety instruction to staff on alternating months, conduct fire drill every other month, and document all required components on fire drill records. Findings include, but are not limited to:

Fire drill and fire safety instruction records were requested for 11/2021 through 05/2022.

Review of the records revealed:

* Fire and life safety instruction was not provided to staff on alternating months; and

* Fire drills were not conducted every other month and records lacked the following components:

- 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;

- Evacuation time period needed; and

- Number of occupants evacuated.

Fire and life safety training and fire drill documentation requirements was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 05/03/22. They acknowledged the findings.

OAR 411-054-0090 C-420 Fire and Life Safety

1. Fire and Life Safety Training will be completed at all staff meeting and/or through Relias online training program.

2. Alternating months will have fire drills with the location,scenario and exits from the fire being different each time. Months between the fire drills will have specific training for fire and life safety through either all staff inservicing, or Relias training.

3. Documentation will be reviewed with the ED after every fire drill.

4. ED/MD will review weekly to assure compliance at QA meeting.

Based on interview and record review, it was determined the facility failed to document all required components on fire drill records. This is a repeat citation. Findings include, but are not limited to:

Fire drill records were requested for 07/2022 through 11/2022.

Review of the records revealed:

Fire drills records lacked documentation of the following required information:

* The escape route used;

* Evacuation time period needed; and

* Number of occupants evacuated.

Fire drill documentation requirements were discussed with Staff 1 (ED) on 11/09/22. She acknowledged the findings.

OAR 411-054-0090 C-420 Fire and Life Safety

1. Documentation will be reviewed with the ED and MD after every fire drill to ensure all details are properly documented. Including but not limited to the escape route used, evacuation time period needed, and number of occupants evacuated

4. ED/MD will review weekly to assure compliance at QA meeting.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

Fire and life safety records for 03/2022 through 04/2022 were provided. Review of the records revealed a lack of documented evidence related to the following required elements:

* Alternate evacuation routes used during fire drills; and

* Documentation of interventions and/or resolution for resident evacuation concerns identified during fire drills.

There was no evidence of instruction, at least annually, in general safety procedures, evacuation methods, and responsibilities during fire drills to residents.

The need to have all components of fire drill and life safety training documented and to provide annual fire and life safety training to residents was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 05/03/22. They acknowledged the findings.

OAR 411-054-0090 C-422 Fire and Life Safety

1. All staff training will be completed at all staff meeting and/or through Relias.

Resident training will be completed to ensure that all residents are able to evacuate safely and are aware of what to do in the event of a fire or other emergency.

Scheduling a resident meeting for fire and life safety training for the first week of June 2022. MD and/or desingee will meet with residents that do not attend the meeting on a one on one basis and complete the training with them.

2.Resident training and assessment for fire and life safety will be completed at move in, and updated as needed during service plan meetings. Documention of interventions and/or resolution for resident evacuation concerns identified during fire drills will be completed and kept in a specific Fire and Life Safety Binder.

3. Documentation will be reviewed with ED each month

4. ED/MD will review monthly for compliance during QA

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 260, C 270, C 310, and C 420.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1. The facility will ensure complete compliance of C 260, C 270, C 310, and C 420 by December 24, 2022.

2.  Refer to the POC in its completeness for compliance.

3.ED/MD/RN/RCC will review compliance process weekly during QA meeting.

Based on interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:

Refer to C 270.

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval

1. The facility will ensure complete compliance of C 270 by April 29, 2023.

2.  Refer to the POC in its completeness for compliance.

3.ED/RN/RCC will review compliance process weekly during QA meeting.

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

The exterior of the facility was toured on 05/02/22. The following issue was identified as needing repaired:

* Exterior sidewalks around the facility had multiple drop offs up to five inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents.

On 05/02/22, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0200 General Building Exterior

1. MD did a walk and inspection of sidewalks with landscaping contractor. Contractor will be sending a bid to ED and MD. Completion of repairs and supplies will be pending availability of contractor.

2. MD will complete a weekly walk through and then will review with ED findings from his walk through during weekly QA meeting

3. ED will review findings of QA walk through with the MD weekly.

4. ED will review with MD during weekly QA meeting.

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

Observations of the facility on 05/02/22 revealed the following:

* Elevator doors had scratched and chipped paint;

* Room 104 and 205 door and door frames were damaged exposing bare wood;

* Hand rails were scratched and scuffed; and

* Scratches in the paint throughout the hallways and common areas of the facility.

The need to ensure the facility environment was kept in good repair was discussed with Staff 1 (ED) on 05/02/22. She acknowledged the findings.

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

1. MD will be painting and ordering supplies needed to repair elevator doors, room 104 and 105 doors/frames, repairing handrails, and walking around the community to paint/repair any findings throught the hallways and common areas.

2. MD will complete a weekly walk through and then will review with ED findings from his walk through during weekly QA meeting

3. ED will review findings of QA walk through with the MD weekly.

4. ED will review with MD during weekly QA meeting.

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

During an environmental walk-through on 05/02/22, the metal surface on the baseboard heaters located in apartments with one or two bedrooms exceeded 120 degrees F when turned on.

The need to ensure residents could not come into incidental contact with baseboard heating elements that exceeded 120 degrees F was discussed with Staff 1 (ED). She acknowledged the findings.

OAR 411-054-0300 (8) Heating and Ventilation

1. MD will inspect the wall heaters and will temporarily disconnect the heaters that are not able to stay under 120 degrees.  

2. ED and MD will evaluate if the heaters will be disconnected and removed, or if they are able to stay under 120 degrees and will need protective covers.

3. Once the heaters are in proper working condition the MD will inspect the heaters monthly and as needed.

4. ED and MD will discuss at weekly QA meeting