Print Inspection: PUW1

The findings of the re-licensure survey, conducted 12/12/23 through 12/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:  activities of daily living

bid: twice a day

CBG: capillary blood glucose or blood sugar

CG: caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH: Home Health

LPN:Licensed Practical Nurse

MA:Medication Aide

MAR: Medication Administration Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:quality improvement

RCC:Resident Care Coordinator

RN:Registered Nurse

TAR:Treatment Administration Record

tid:three times a day

The findings of the first revisit to the re-licensure survey of 12/14/23, conducted 03/18/24 through 03/19/24 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 12/14/23, conducted on 05/14/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents for 2 of 2 sampled residents (#s 1 and 4) who used call pendants. Findings include, but are not limited to:

During the survey process, 12/12/23 through 12/14/23, the following was identified:

a. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure. Record review and interviews revealed the following:

Resident 4 experienced a fall on 11/18/2023 at 3:45 am.

In an interview on 12/13/23, Witness 2 (Family member) reported Resident 4 had pressed his/her call pendent for assistance after a fall and had waited approximately 30 minutes for assistance. When staff did not come, Resident 4 called a family member for assistance. The family member called the facility's front desk who had caregiving staff respond and assist Resident 4 off the floor.

The resident's fall on 11/18/23 was discussed with Staff 5 (Health and Wellness Director) on 12/14/23. He explained the reason why staff did not come sooner to assist the resident when s/he used the call pendant was that either Resident 4 did not push it hard enough or the pendant's battery was not functional. Staff 5 was not able to provide evidence the call pendant was checked by staff to indicate if the pendant was in working order following the fall. He was unable to report how often call light pendants and batteries were checked and tested for functionality, but stated it was a maintenance task.

There was no documented evidence Resident 4's call pendent was tested to determine functionality after experiencing a fall and pressing his/her call pendant.

b. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and high blood pressure.

The resident's move-in evaluation, dated 09/22/23, stated the resident would "utilize a pendant for safety" and identified three times that the resident had previously fallen.

The resident experienced an unwitnessed fall in his/her room at 5:10 pm on 10/29/23. The occurrence report stated the resident "had to scoot to the wall to call us since [his/her] wrist button wasn't working."

In an interview on 12/14/23, Staff 3 (Assisted Living Director) reported that after the fall, she replaced the battery on Resident 1's wrist pendant. She stated she was not aware of a current process for monitoring or checking call pendant batteries, though she believed this was performed by the maintenance team.

During an interview on 12/14/23, Staff 7 (Maintenance) stated he was not aware of a current system or process in place to check call light pendants and batteries. He stated that at this time, he only replaces single batteries or pendants as needed when a caregiver notifies him that one has not worked when a resident called for help.

The facility lacked documented evidence that there was a system in place for monitoring the effectiveness of residents' call pendants.

On 12/14/23, the need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 3 and Staff 5. They acknowledged the findings.

1. All residents with call pendants will have them monitored monthly for operational status. This will include testing for funtional ability and replacement of batteries. This will be completed by the maintenance director.

2. Resident ability to activate call pendants will be assessed quarterly at service plan update meeting to ensure that resident is still able to activate call pendant appropriately.

3. Resident preference will be assessed quarterly at service plan update meeting to determine how resident would prefer to wear call pendant, either as a necklace style pendant or as a wrist watch style call pendant.

4. All residents issued a new pendant, either being a new move in to the community or an existing resident choosing to utilize a pendant will be instructed on how to properly activate their pendant and when to notify the community if it does not appear to be functioning correctly. This will be documented in the resident chart.

5. Items mentioned in steps 2-5 will be completed by the Assisted Living Director.

6. The Executive Director will review these items weekly for completion.

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.

Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), and Alert Charting records were reviewed during the survey. Interviews were conducted with caregiving staff and the resident.

The current service plan, dated 12/07/23, lacked information regarding Resident 5's private caregiver including:

* Name and contact information for the home health agency providing the service;

* The name of the private caregiver;

* The private caregiver's schedule; and

* Instructions for providing additional care, if necessary, at times when the private caregiver was not on-site.

The lack of information about the private caregiver and instructions for facility caregivers for ensuring care was provided when the private caregiver was not on-site was reviewed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the information lacking from the service plan.

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

1. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath.

The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 Charting Notes, and Resident Temporary Care Plans were reviewed. Staff were interviewed and observations were made of the resident. The following areas of the service plan were not reflective of the resident's current care needs and did not provide clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services should be provided:

* Continuous positive airway pressure (CPAP) use including assistance needed with the mask and water, and what to do if staff noticed it was in disrepair;

* Pacemaker placement;

* Outpatient PT services;

* Short-term memory loss;

* Interventions relating to cognition deficits;

* Personalized interventions for behaviors;

* What triggered the resident's behaviors;

* Environmental factors that impact the resident's behavior;

* Activities of interest both in the facility and independently;

* Assistance needed for dressing;

* Cueing needed for personal hygiene tasks;

* Toileting assistance and brief use; and

* Staff to monitor for bruising relating to a blood thinning medication.

The need for service plans to accurately reflect residents' current needs and provide clear instructions to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis.

The resident's current service plan, dated 09/09/23, was reviewed, observations were made, and interviews with staff were conducted. Resident 3's service plan was not reflective of the resident's status in the following areas:

* Modified diet texture; and

* Home Health therapies.

In addition, Resident 3's service plan did not provide instructions to caregivers on the correct use of side rails and precautions related to their use.

The need to ensure service plans reflected the residents' needs and provided clear direction to staff was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Service plans for residents 2, 3, & 5 have been updated.

2. Resident service plans will include detailed information on outside providers being utilized by residents such at PT/OT, home health, private caregivers, medical supply services, who to contact for repairs to resident equipment, etc.

3. Pre-move in evaluation tool will be updated to reflect resident use of devices and services not clearly defined in current tool.

4. Resident service plans will clearly outline a detailed description of what service is to be provided, by whom, when, how and frequency with which the service will be provided.

5. Resident service plans will be reflective of resident preferences, resident specific plans to address needs.

6. All service plans will be completed by the Assisted Living Director.

7. Staff will be inserviced weekly to ensure they understand the need to provide services to residents in  a manner than respects and upholds their independence and dignity. This training will be conducted by the Health & Wellness Director.

8.  The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to determine, document, and communicate to staff what action or intervention was needed for a resident in response to a short-term change of condition, and failed to document weekly progress until the condition resolved, for 2 of 5 sampled residents (#s 1 and 5) who experienced changes of condition requiring monitoring. Findings include, but are not limited to:

1. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.

Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCPs), and Alert Charting records were reviewed during the survey.

The resident experienced the following changes of condition:

* 09/18/23, 10/11/23, and 11/15/23: Significant weight gains; and

* 11/27/23: Change in behavior including increased confusion, fearful, wanting to leave building, and grasping his/her cat unsafely.

The following deficiencies were identified:

a. The facility wrote a TCP in response to each weight increase. Each TCP included the following interventions:

* Offer or encourage healthier choices at meals; and

* Encourage more physical activity such as walking around the facility.

The facility failed to include instructions for staff as to what to monitor and document. There was no documented evidence the facility monitored whether the interventions were attempted by caregivers, whether the resident was agreeable to trying the interventions, or whether the interventions were effective in meeting the treatment goal.

b. The facility instituted its alert charting process in response to the change in behavior on 11/27/23 by creating an Alert Charting entry electronically. Review of the Alert Charting entry with Staff 5 (Health and Wellness Director) on 12/14/23 indicated the entry lacked resident-specific instructions for staff as to what behaviors staff should monitor and report or document on.

The need to ensure the facility provided resident-specific instructions for what exactly to monitor and document following a resident's change of condition was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 on 12/14/23. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia.

Observations of the resident, interviews with staff, and review of the resident's most recent service plan, dated 11/08/23, Shift-to-Shift Communication Logs, Temporary Care Plans, Occurrence Reports, physician communications, and Charting Notes from 09/12/23 through 12/11/23 were completed.

The facility record lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution for the following short-term changes of condition:

* 10/04/23: New medication: Coumadin (blood thinner);

* 10/22/23: Missed medication: metoprolol (for high blood pressure); and

* 10/29/23: Unwitnessed fall with injury.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift, and changes of condition were monitored through resolution, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on the proper use of temporary service plans (TSP's). This training will be conducted by the Health & Wellness Director.

2. TSP's will include clear directions to staff on what happened to said resident, interventions to reduce the risk of harm to the resident in the immediate moment as well as interventions to prevent future reoccurrences from happening.

3. TSP's will include specific information for staff to identify what to observe and report on pertaining to the specific event.

4. Staff will be inserviced  weekly on the alert charting process to include making proper opening and closing alert charting notes. This training will be conducted by the Health & Wellness Director.

5. Alert charting will contain more resident specific directions for staff to identify what to report and document on when being placed on alert charting. This will be completed by the medication aids when placing a resident on alert charting.

6. The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols during meal service. Findings include, but are not limited to:

During lunch service on 12/12/23 and 12/13/23 multiple care staff, who performed duties including resident ADL care, were observed assisting with meal service, which included entering the kitchen to obtain food for the residents. Though the kitchen staff were wearing aprons, care staff did not don aprons or some other barrier to prevent potential cross contamination when assisting with meal service.

The need to establish and maintain infection prevention and control protocols, including protocols to prevent the development and transmission of communicable diseases, was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on infection control policy and preceedure to include proper handwashing. This training will be conducted by the Health & Wellness Director.

2. Care staff will wear an apron at all times when acting as a server in dining room between duties as a caregiver. Care staff will place dirty aprons in the garbage can specified in the AL drink station for dirty aprons.

3. These aprons will be laundered by the facility daily to ensure cleanliness. Laundry will be completed daily by the NOC care staff.

4.The Executive Director will review these items weekly for completion.

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

During the re-licensure survey, conducted 12/12/23 through 12/14/23, professional oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in the following area:

* C 303: Medication and Treatment Orders.

On 12/14/23, the delays in updating the MAR with new orders, obtaining new prescriptions, and administering medications as ordered was reviewed with Staff 5 (Health and Wellness Director). When asked to explain the current process for auditing resident MARs, he stated the MARs were audited once per month.

On 12/14/23, Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 were informed the oversight of the medication administration system was determined to be inadequate based on the medication type and potential impact on the resident and the extended length of time the facility was administering medications to residents which did not align with the current physician orders. They acknowledged the findings.

1. MAR reviews will be conducted twice monthly by the Health & Wellness Director to increase frequency of quality control checks for accuracy.

2.The Executive Director will review these items weekly for completion.

2. Resident 1 was admitted to the facility in 09/2023 with diagnoses including history of subdural hematoma and osteopenia.

The resident's MARs, dated 10/01/23 through 12/11/23, and all physician orders were reviewed.

a. The resident had a physician's order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/18/23 at 10:10 am, for changes to Coumadin (blood thinner) administration, to be followed until new orders were received. The MAR was not updated between 10/14/23 and 10/30/23, resulting in the resident receiving an incorrect dosage of Coumadin on the following dates:

* 10/18/23;

* 10/20/23;

* 10/25/23; and

* 10/27/23.

b. The facility did not carry out prescribed physician orders for metoprolol (for high blood pressure), resulting in the resident not receiving medication on:

* 10/21/23; and

* 10/22/23.

c. The facility did not carry out prescribed physician orders for Coumadin from 10/31/23, resulting in the resident receiving 2.5 mg instead of 5 mg on 10/31/23.

d. The facility did not carry out prescribed physician orders from 11/04/23 indicating the resident should receive 5 mg of Coumadin daily. The MAR was blank, with no documented evidence the resident received Coumadin on the following dates:

* 11/05/23;

* 11/06/23; and

* 11/07/23.

e. Medications and a treatment on 12/06/23 were not provided per physicians orders, including metoprolol, Coumadin, lidocaine patch (for pain management), and wound care to the right forearm. The MAR exception stated "medication given late," but in an interview on 12/12/23 Staff 9 (MT) stated the resident did not receive the medications and treatment.

The need to ensure all orders were carried out as prescribed was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 07/2023 with diagnoses including Parkinson's disease and spinal stenosis.

Review of the resident's physician orders included an order dated 10/18/23, with a fax stamp indicating the facility received the order on 10/19/23, for midodrine (for Parkinson's disease) increased from 2.5 mg three times a day to 5 mg three times a day.

The 11/2023 MAR listed the 2.5 mg order stop date as 11/03/23, and the 5 mg order origination date as 11/03/23, with documentation of 2.5 mg given through 11/02/23 and increased to 5 mg on 11/03/23. There was no documented evidence the medication started on 10/19/23, per physician's orders.

Staff 4 (RN) reported in an interview on 12/13/23 that she did not know why the medication had not been increased to 5 mg until 15 days after the order was received.

The need to ensure all medications and treatments were administered as prescribed by the physician was reviewed with Staff 3 (Assisted Living Director), Staff 4, and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

1. Staff will be inserviced weekly on properly entering a physician order, the 4 step approval process,what constitutes a legal written physician order. This training will be conducted by the Health & Wellness Director.

2. Daily review of medications availability by the Assisted Living Director and Health & Wellness Director will occur to ensure that all resident medications are received in a timely manner and communicated to residents providers.

3.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility administered for 3 of 3 sampled residents (#s 7, 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 01/2023 with diagnoses including dementia and congestive heart failure .

The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following:

* On 02/05/24 a decreased dose of Lisinopril to 20 mg a day was ordered for a duration of 30 days; and

* Furosemide 20 mg a day was ordered for 30 days.

The MAR indicated both medications were administered starting on 02/06/24 and should have stopped after the 03/06/24 administration. The Lisinopril 20 mg and Furosemide continued to be administered after the 30 days through 03/18/24 when the surveyor notified Staff 4 (RN). The RN acknowledged the findings and reported she would contact the physician immediately for further orders.

* On 03/06/24 Bacitracin-neomycin-polymyxin ointment was ordered to be applied to the skin twice daily (wound right forearm). The MAR revealed the facility was documenting administration of the ointment one time daily, not twice daily as was ordered.

The need to ensure physician's orders were carried out as prescribed was discussed with RN and Staff 6 (Director of Health Services) on 03/18/24, and Staff 2 (ED), Staff 5 (Previous Health and Wellness Director) and Staff 17 (Regional Director of Operations) on 03/19/23. They acknowledged the findings.

2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia, type 2 diabetes and hypertension.

The resident's MAR, dated 02/01/24 through 03/18/24, charting notes from 02/14/24 through 03/18/24, and physician's orders were reviewed and revealed the following:

The resident was administered sulfamethoxazole-trimethoprim 800-160 mg (for urinary tract infection) between the dates of 02/15/24 through 02/20/24.

Charting notes from 02/15/24 stated the medication was dropped off at the facility by the resident's daughter.

The facility was unable to provide any documentation that a physican's order was received for this medication.

The need to ensure signed physician's orders were documented in the resident's record for all medications the facility administered was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings.

3. Resident 9 was admitted to the facility in 01/2022 with diagnoses including congestive heart failure and type 2 diabetes.  

The resident's MAR, dated 02/01/24 through 03/18/24, and physician's orders were reviewed and revealed the following:

The resident had a physicians order, dated 01/15/24, for ergocalciferol 5,000 unit tablet (for severe vitamin deficiency) to be given once every week for eight weeks, then switched to 1,000 unit tablets daily thereafter.

The resident's MAR showed that the facility was continuing to administer the 5,000 unit tablet after the ordered eight weeks had been completed. The facility had also been simultaneously administering the 1,000 unit dose daily throughout the look-back period.

The need to ensure all medication orders were carried out as prescribed was discussed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations) on 03/18/24 and 03/19/24. No additional information was provided, and they acknowledged the findings.

1) R#7:  Bacitracin order was re-written correctly.  Fax sent to MD to clarify longevity of orders for Lisinopril and Furosemide dosing.   R#8:  Request sent to MD for copy of antibiotic order.  R#9:  MAR corrected for documentation error on the vitamin suppliment.  A MAR audit of remaining residents conducted to verify accuracy in order transcription and utilization.  Re-education for MT staff on proper order transcription process will be provided by 4/12/24.

2) Weekly MT meetings with a focus on routine audit findings will be conducted for 30 days then will resume monthly or more as need identified.  ALD/MCD will conduct daily order transcription review for new incoming orders and twice monthly MAR audits to assure accuracey.

3) Daily order transcription review and twice monthly MAR audits

4)  ALD/MCD with ED/Designee oversight

3. Resident 5 was admitted to the facility in 01/2023 with diagnoses including dementia.

Resident 5's Charting Notes from 09/18/23 through 12/04/23, service plans, Temporary Care Plans (TCP), Alert Charting records, and the resident's ABST data were reviewed during the survey. Interviews were conducted with caregiving staff and the resident.

Resident 5 had a private caregiver who provided ADL care for approximately four hours per day on Monday thru Friday. No private caregiving was scheduled on the weekends.

The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:

* Assisting with ambulation, escorting to and from meals or activities;

* Supervising, cuing or supporting while eating, including tray delivery and pick-up;

* Cuing or redirecting due to cognitive impairment or dementia;

* Ensuring non-drug interventions for behaviors; and

* Monitoring behavioral conditions or symptoms.

The need to ensure Resident 5's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 09/2022 with diagnoses including artherosclerotic heart disease, hypertension, and shortness of breath.

The resident's 09/27/23 service plan, 09/29/23 through 12/04/23 progress notes, Resident Temporary Care Plans, 11/01/23 through 12/11/23 MARs, and Resident 2's ABST data was reviewed. Staff were interviewed and observations were made of the resident.

a. The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:

* Personal hygiene;

* Responding to call lights;

* Leisure activities;

* Non-drug interventions for behaviors;

* Redirecting due to cognitive impairment or dementia;

* Passing out medications;

* Escorting to and from meals or activities;

* Helping with bowel and bladder management; and

* Grooming.

During multiple observations on 12/12/23 and 12/13/23, the resident requested or required staff's assistance with responding to call lights, escorting to and from meals or activities, interventions for behaviors, and redirecting due to cognitive impairment. However, either no staff time, or an insufficient amount of staff time, was assigned to these elements in Resident 2's ABST.

b. There were no minutes assigned for the "NOC" shift (from 10:00 pm to 6:00 am); however, there was documented evidence the resident received PRN medications and staff were providing Resident 2 care and companionship during the shift.

The need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director), Staff 4 (RN), and Staff 5 (Health and Wellness Director) on 12/14/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to develop an acuity-based staffing tool (ABST) that reflected an accurate time frame needed for each component to generate an accurate staffing plan for 3 of 5 sampled residents (#s 2, 4, and 5) whose ABST data was reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 09/2021 with diagnoses including high blood pressure and hypertension.

The resident's 12/01/23 service plan, 11/15/23 through 12/12/23 progress notes, Resident Temporary Care Plans, and ABST data was reviewed. Staff were interviewed and observations were made of the resident.

The following ADL elements were not reflective of the time it would take for facility staff to complete the task or the frequency for which the care was provided. Examples include:

* Providing treatments (e.g. skin care, wound care);

* Transferring in or out of bed or a chair;

* Helping with bowel and bladder management;

* Dressing and undressing; and

* Additional care services such as pet care.

On 12/14/23, the need to ensure resident's ABST data was accurate to develop the facility's staffing plan was discussed with Staff 3 (Assisted Living Director) and Staff 5 (Health and Wellness Director). They acknowledged the findings.

1. ABST tool will be updated upon resident move in, residents sent out to the hospital or skilled nursing facilities (SNF), quarterly service plan updates or change of condition. This will be performed by the Health & Wellness Director.

2. The Health & Wellness Director will update the ABST tool weekly with all resident updates from quaterly service plan updates.

3. The Health & Wellness Director will ensure all new move ins are entered into the ABST tool prior to move in to the community.

4. The Health & Wellness Director will ensure that all residents are updated in the ABST tool when out of the community in the hospital or a SNF.

5.The Executive Director will review these items weekly for completion.  

Based on interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) assessment for two unsampled residents and update the ABST after a significant change of condition for 1 of 2 sampled residents who experienced a significant change of condition (#8). This is a repeat citation. Findings include, but are not limited to:

1. The facility's ABST was reviewed upon survey entrance on 03/18/24. Two unsampled residents did not have minutes entered to reflect their care needs.

2. Resident 8 was admitted to the facility in 05/2022 with diagnoses including dementia and type 2 diabetes.   

Review of the resident's ABST showed it was last updated on 01/06/24.

On 02/29/24, the resident returned to the facility from a hospital stay. A significant change of condition assessment was completed by Staff 4 (RN) on 03/01/24 and described the resident's increased level of confusion, generalized weakness, and need for increased assistance from staff including "monitoring resident frequently" and "offer assistance to meals." The ABST was not updated to reflect the resident's care needs following the significant change of condition.

The need to ensure an ABST assessment was completed for all residents and updated after significant changes of condition was reviewed with Staff 2 (ED), Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations). They acknowledged the findings, and no additional information was provided.

1) Sampled residents were immediately added to the ABST tool.  ABST tool was reviewed for sampled R#8 to assure accuracy.  A review of the ABST tool for residents with changes of condition in the last 14 days will be conducted to assure accuracy.

2) Training on the ABST tool and review protocol was provided to the Executive Director and new Assisted Living Director and new Wellness Director to assure understanding.  ABST tool will be reviewed at least twice monthly and/or with new admits/discharges and those with changes to care needs.

3) At least twice monthly and/or with new admits/discharges and those with changes to care needs

4) ALD/Wellness Director/ED or Designee

Based on interview and record review, it was determined the facility failed to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting for 2 of 2 long-term staff (#s 9 and 15) whose training records were reviewed and failed to ensure all staff completed annual training on infectious disease outbreak and infection control for 1 of 2 non-care staff (#16) whose training records were reviewed. Findings include, but are not limited to:

Training records were reviewed with Staff 1 (ED) on 12/13/23. The following deficiencies were identified:

1. Based on review of training records, the facility conducted monthly in-service training for all staff which included training on topics related to the provision of care for persons in a community-based care setting, but did not document the portion of time specifically spent on such topics. As a result, Staff 9 (MA), hired 03/2022, and Staff 15 (CG), hired 11/2022, failed to have documented evidence of completing 12 hours of required annual in-service training, based on their anniversary date of hire.

2. Based on review of training records, Staff 16 (Housekeeping), hired 10/2012, failed to have documented evidence of completing annual training on infectious disease outbreak and infection control. The facility provided evidence that Staff 16 completed the training on 12/12/2023 while the survey team was on site.

The need to ensure direct care staff completed and documented a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting and ensure all staff completed annual training on infectious disease outbreak and infection control was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. All staff training will have amount of time dedicated to each specific topic indicated on signature sheet.

2. All staff will complete annual infection control and infectious disease outbreak training annually as determined by facility.

3. All staff will complete this training by being scheduled monthly throughout the course of the year to ensure compliance with annual expiration dates.

4. All staff training will be managed by the Assistant Executive Director.

5.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills according to the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

On 12/12/23, fire drill and fire and life safety records for the previous six months were requested. Review of the documentation provided revealed:

1. Staff did not evacuate or relocate residents during all fire drills. Therefore, fire drill records did not include information on:

* 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.

2. There was no documented evidence the facility provided fire and life safety training to staff on alternate months.

The need to ensure the facility conducted unannounced fire drills according to the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. Facility will document each month the escape route used, problems or issues encountered during the course of the drill, residents who refused to participate in the drill, what is the plan to encourage future participation, the time needed to evacuate and the number of eople evacuated.

2. The facility will provide fire and life safety training to staff on alternating months. The community has created a schedule which dictates which months will be designated for training and which topic will be discussed as well as which shift a fire drill will be executed on each month.

3. Fire drills and training will be provided monthly and documented by the maintenance director.

4.The Executive Director will review these items weekly for completion.

Based on interview and record review, it was determined the facility failed to document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:

Fire and life safety records dated 02/14/24 through 03/18/24 were reviewed on 03/18/24. Fire drill documentation did not include one or more of the following required elements:

* Time of fire drill;

* Location of simulated fire origin;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

The need to follow all OFC requirements for fire drills and documentation was discussed with Staff 2 (ED), Staff 17 (Regional Director of Operations), Staff 6 (Director of Health Services), and Staff 5 (Previous Health and Wellness Director) on 03/19/24. They acknowledged the findings. No additional information was provided.

1) Information missing to the reviewed fire drill were added.  Retraining provided to the Maintenance Director to assure understanding of proper completion of the fire drill documentation was completed.

2) Executive Director will review fire drill documents weekly with Maintenance Director to assure all elements are addressed as per regulations for each fire drill conducted.

3) Weekly

4) Executive Director/Maintance Director

Based on interview and record review, it was determined the facility failed to re-instruct each resident, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire and failed to keep a written record of fire safety training. Findings include, but are not limited to:

On 12/12/23, Staff 2 (Assistant ED) stated prior to each fire drill all residents were given a handout with instructions regarding what to do during a fire drill. However, Staff 2 was unable to produce a copy of the handout. Also, the facility had no written record of fire safety training, including content of the training sessions and the residents attending.

The need to ensure residents were re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places and the facility kept a written record of fire safety training was discussed with Staff 1 (ED) and Staff 2 on 12/12/23. They acknowledged the findings.

1. The community will ensure that all residents understand what to do in the event of a fire by reviewing the fire safety proceedure with residents upon move in during contract signing. This will be done by either the Assistant Executive Director or the Executive Director.

2. The community will ensure ongoing resident fire safety education by scheduling annual fire safety re-orientation and documenting attendance with a resident signature sheet along with attached training content. This training will be conducted by the maintenance director.

3. All residents not in attendance at the annual orientation will receive one-on-one instruction from the maintenance director and will be documented on the annual orientation signature sheet.

4.The Executive Director will review these items weekly for completion.

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

Refer to C 303, C 361, C 420 and C 630.

Immediate corrections to the findings noted during the survey were initiated and completed during the survey visit.

see individual plans of correction under each tag

Executive Director will review POC weekly with applicable department heads to assure execution

Executive Director

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

On 12/12/23, during a tour of the exterior and interior of the facility, the following were identified:

* Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop-offs up to approximately four inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents; and

* Cabinets in the second floor kitchenette were unlocked and contained toxic chemicals.
 

On 12/13/23, the exterior drop-offs and the unlocked interior chemicals was toured and reviewed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. All exterior pathways surrounding the community and courtyard have been brought level with sidewalks with the addition of bark mulch.

2. These walkways will be monitored weekly for continued comliance by the maintenance director.

3. Bark mulch will be added to any walkways as needed to prevent uneven surfaces and potential for fall hazards. This will be completed as needed by the mainteance director.

4. All chemicals in the 2nd floor kitchenette have been removed. This will be completed by the Assistant Executive Director.

5. Chemicals will not be stored in the 2nd floor kitchenette.

6.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

On 12/12/23, the facility interior was toured. Multiple vertically opening windows above the first floor, with window sills lower than 36 inches from the floor, lacked a system which limited how far the window could be opened to prevent accidental falls.
 

On 12/13/23, the lack of a mechanism to prevent accidental falls from upper floor windows was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. All windows above the 1st floor will have a device installed to limit how far the window is able to be opened so as to prevent a human body from falling out of the window.

2. These devices will be installed by the maintenance director.

3.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure the stove in the activity room had a keyed remote switch or safety device to ensure staff control. Findings include, but are not limited to:

The interior of the facility was toured on 12/12/23. The stove in the activity room, located on the second floor and accessible to all residents, was able to be turned on without the use of a key, remote switch, or other safety device to ensure staff control.

On 12/13/23, the need to ensure a safety device was used for the stove when staff were not present was discussed with Staff 2 (Assistant ED) and Staff 7 (Maintenance). They acknowledged the findings.

1. The stove in the activity room on the 2nd floor will have a timer installed to deactivate the power to the stove after a specified amount of time.

2. The maintenace director will arrange for a licensed electrician to install this timer device.

3.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. Findings include, but are not limited to:

During a tour of the facility laundry rooms on 12/12/23 and 12/13/23, it was observed the facility washed all linens and clothing in residential washers. There was no documented evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize the soiled items. Interviews with Staff 14 (Housekeeping) and Staff 13 (CG), stated they washed soiled linens and soiled clothing, respectively, in accordance with instructions posted by the facility in each laundry room. The instructions did not include direction to use a chemical disinfectant when washing soiled linens and clothing.

The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 12/12/23. They acknowledged the findings. No further information was provided.

1. Staff will be inserviced weekly on the proper way to handle laundry soiled with bodily fluids. This training will be conducted by the Health & Wellness Director.

2. Facility will provide documentation that the soap used to launder resident laundry contains sanitizing agents appropriate to clean and sanitize washing machines after use. This documentation will be provided by the Assistant Executiove Director.

3. Facility will post proper signage instructing staff on the proper procedure for handling of soiled laundry. This signage will be posted by the maintenance director.

4.The Executive Director will review these items weekly for completion.

Based on observation and interview, it was determined the facility failed to ensure that when washing soiled linens and soiled clothing washing machines had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to:

During a tour of facility laundry rooms on 03/18/24 and 03/19/24, it was observed that facility staff washed linens and clothing in residential washers on floors one through three. There was no evidence the washers had a minimum rinse temperature of 140 degrees Fahrenheit to sanitize soiled items.

When asked how soiled linens and soiled clothing were washed, staff reported they used the resident's personal laundry detergent, and if they did not have one, they would then use the facility-provided powdered detergent. The detergent was provided to staff in a glass bowl with a small plastic cup inside. There was no marking on the cup or instructions posted to indicate how much of the detergent to use or that it should be used for soiled linens and soiled clothing. There was no posted signage in any of the laundry rooms which described the need to use a chemical disinfectant when washing soiled linens and clothing.

Posted in the second floor laundry room, there was a hand-written sign which stated "Before putting soiled laundry in machine first rinse thoroughly in residents shower put in trash bag to get it to laundry room then put in machine cold water cycle."

During interviews with Staff 6 (Director of Health Services) and Staff 17 (Regional Director of Operations), they stated the soiled linen handling policy had been reviewed at an employee in-service on 12/28/23 and 01/04/24. They acknowledged that the current posted soiled laundry policy did not include information about use of a chemical disinfectant.

The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 2 (ED), Staff 6 and Staff 17 03/19/24. They acknowledged the findings, and no additional information was provided.

1) Proper detergent was placed in all laundry rooms during the visit. Re-education on purpose and expected use of this detergent was provided to all applicable staff by 4/12/24.

2) Ongoing oversight of the laundry rooms for adequate detergent available and proper use of hopper rooms.

3)  Weekly

4) Executive Director/Designee