Print Inspection: R4MV

The findings of the re-licensure survey, conducted 04/25/22 through 04/27/22, 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 first revisit to the re-licensure survey of 04/27/22, conducted 01/23/23 through 01/24/23 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.

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 04/25/22 through 04/27/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.

Refer to deficiencies in report.

Refer to all other components of Plan of Correction.

Letter of Agreement in place and active with progress reports every other week beginning May 23, 2022.

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 04/25/22 through 04/27/22, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

Refer to the deficiencies in the report.

Refer to all other components of Plan of Correction.  

Quarterly QAPI meetings in place to assure quality improvement oversight resulting in adequate resident care, services, satisfaction, and staff performance.  

Based on observation, interview and record review, it was determined the facility failed to ensure 1 of 1 sampled resident (#1) was treated with respect and dignity. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia.

A review of the current service plan, temporary care plans, incident reports and interviews with staff were conducted during the survey.

On 04/26/22 at 11:08 am, the resident's door was open to the hallway. The resident was observed lying in bed, which was positioned next to a large window with the blinds open. The resident was not wearing a shirt or pants. The resident had on an incontinence brief and a thin white blanket partially covered the brief. The remainder of the resident's body was exposed.

The resident had garbled speech and difficulty stating his/her preference for not wearing any clothing. The surveyor used the resident's call pendant to alert staff. Staff 8 arrived seven minutes later to assist the resident to get up and put clothes on.

A review of the service plan dated 01/19/22 indicated the resident required assistance with dressing.

The above observation was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Services Director) on 04/26/22. Staff 1, 2 and 3 were unable to confirm if this was the resident's preference, however acknowledged the window blinds needed to be closed for privacy.

On 04/27/22 at 9:30 am, the resident's door was open to the hallway. The resident was observed lying in bed with the blinds open. The resident was not wearing a shirt or pants. The resident had on an incontinent brief and a thin white blanket partially covered his/her body.

Staff 3 alerted Staff 1 and 2, who immediately entered the resident's apartment, closed the door and assisted the resident with dressing for the day.

The facility failed to ensure the resident received services in a manner that preserved privacy, dignity and respect.

The above findings were discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22 at 10:05 am. They acknowledged the findings.

1).  After further observation and review, resident noted disrobing down to briefs when in bed per historical preference.  Preferences and habits are noted in service plan.  While in bed, blinds are maintained in semi-closed position also per resident preference.  Resident is provided with sheet and/or blanket as desired for dignity.  

2). Personal preferences related to privacy, dignity, and respect are noted on individual service plans to the extent known.  Additionally, all staff have participated in additional training via Oregon Care Partners with regard to resident rights, dignity, and reporting of potential neglect/abuse as well as provided written list of Resident Rights for review and signed acknowledgment.  

3). Privacy, preservation of dignity, and attention to respect are continually monitored for all residents with any personal preferences/tendencies being noted on each service plan as appropriate.  Preferences are evaluated at minimum on a quarterly basis and as needed/identified.  

4). Executive Director/Assistant Director, Nurse, and Resident Care Coordinator (RCC) aka the Administrative Team to assure compliance.

Based on interview and record review, it was determined the facility failed to thoroughly investigate incidents of unwitnessed injury falls to reasonably conclude the incident was not the result of suspected abuse or neglect and failed to report to the local SPD office for 1 of 1 sampled resident (#1) who had unwitnessed injury falls. Findings include, but are not limited to:

During the entrance interview on 04/25/22, Resident 1 was identified with multiple injury falls.

Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia and had a history of falls.

The following fall interventions were documented in the resident's 01/19/22 service plan:

* Keep pathways clear;

* Reminders to use front wheel walker;

* Regular medication review to prevent falls;

* Two hour safety checks during night shift; and

* Complete quarterly fall assessment.

A review of progress notes and incident reports identified the following:

Resident 1 had experienced seven unwitnessed injury falls from 01/13/22 through 04/21/22.

The facility failed to conduct immediate investigations which reasonably concluded the falls with injuries were not the result of abuse/neglect.

The need to ensure all incidents were thoroughly investigated and reported to the local SPD office if abuse or neglect could not be reasonably ruled out was discussed with Staff 1 (ED), Staff 3 (Assistant ED) Staff 3 (Health Services Director) on 04/26/27. They acknowledged the findings.

The facility was directed to self-report the incident to the local SPD office. Confirmation of the report was received on 04/27/22 prior to survey exit.

1). The incidents have been investigated, new interventions implemented, and reported to APS.  The identified resident remains safe.

2). Incidents are investigated timely by administrative staff.  All staff have participated in additional in-depth training regarding reporting responsibilities.  

3). Incidents are reviewed on occurance and are reviewed quarterly during QAPI meetings.  

4). Administrative Team to assure compliance.

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

On 04/25/22 at 9:45 am, the kitchen was toured and observed to need cleaning and repairs in the following areas:

a. Food spills, splatters, debris, dust and black matter was observed on or underneath the following:

* Interior of cupboards and cabinets, including dust and debris on pipes;

* Inside doors and bottom floors of refrigerators and freezers;

* A fan on the floor by the dry food storage room;

* Baseboards and walls;

* The metal transition strip on the floor at the back door that led outside;

* Cobwebs on the wall by the back door;

* The oven grills, burners and inside the oven;

* Floor surfaces beneath the dish machine, ice machine and steam table; and

* Ceiling vents.

b. The following areas needed repair:

* Wooden door frame panels had chips, cracks and gouges with exposed wood; and

* There was a pink plastic wash basin and a metal container on the floor beneath the ware washer. Discolored, pooled water was visible on the floor underneath the basin and metal container.

c. Additional observation:

* The back door leading outside was propped open, posing a risk of poor prevention of insects and rodents entering the kitchen area. Staff closed the door upon request.

The need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed and the kitchen was toured with Staff 1 (ED) on 04/25/22 at 10:30 am. She acknowledged the findings.

1).The kitchen was professionally cleaned 05.09.2022.

2).Cleaning schedules are in place and in use with the new Dining Services Director.  Night shift staff have been trained and the kitchen is cleaned each night as well as professionally cleaned on a quarterly basis.  

3). Monthly kitchen cleanliness audits will occur ongoing.

4). Dining Services Director, Nurse, and Executive Director to assure compliance.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations were completed and addressed all required elements prior to the move in for 1 of 1 sampled resident (#3) whose record was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in March 2022.

Resident 3's records were reviewed on 04/25/22.

There was no documented evidence that a move-in evaluation was completed and addressed all required elements prior to the move-in date.

The need to ensure move-in evaluations were completed and addressed all required elements prior to move-in was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) 04/25/22 at 1:30 pm. They acknowledged the findings.

1). The hand-written pre-evaluation performed by the former nurse was located during the survey and utilized to complete a 30-day evaluation prior to completion of the survey and provided to the survey team.

2). Initial evaluations are performed prior to move-in and are published to the individual's record.  

3). Compliance will be assured with each move-in ongoing.

4). Administrative Team to assure compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were completed,  reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:  

1. Resident 3 was admitted to the facility in 03/2022 with diagnoses of Atrial fibrillation and risk of falls.

Resident 3's records were reviewed on 04/25/22.

There was no documented evidence an initial service plan, reflective of the resident's needs and providing clear direction to staff on delivery of services, was completed.

The need to ensure resident service plans, reflective of resident needs and providing clear direction to staff regarding delivery of services, were completed was discussed with Staff 1 (ED) and Staff 3 (Health Services Director) 04/25/22 at 1:30 pm. They acknowledged the findings

2. Resident 1 was admitted to the facility in 10/2019 with diagnosis including, vascular dementia, insulin dependent diabetes, and congestive heart failure.

Observations of the resident, interviews with staff, review of the service plan dated 01/19/22, and temporary care plans showed the service plan was not reflective of the resident's current care needs, had not been updated when the resident experienced a significant change of condition, and did not provide clear direction to staff in the following areas:

* Cognition, including memory, orientation, confusion and decision making ability;

* Communication and speech;

* Weakness and pain in legs and hip;

* Fall interventions, including the use of fall mat;

* One-two person transfers;

* Mobility, including the use of a manual wheelchair;

* Toileting assistance and incontinent care;

* Use of an electric hospital bed with bilateral side rails;

* Weight bearing status;

* Full assistance with dressing and grooming; and

* Diabetic nail care.

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff  and were updated after significant changes of condition was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Services Director) on 04/26/22 at 12:30 pm. They acknowledged the findings.

1). Service plans for identified individuals were developed during survey and provided to the survey team.  

2). Service plans for all residents are in place and have been reviewed.  Routine auditing for presence of service plans will occur on admission, with change of condition, and quarterly.

3). Compliance with service plans will occur at least quarterly as part of QAPI.

4). Administrative Team to assure ongoing compliance.  

2. Resident 2 was admitted in 2019 and had a history of falls and skin injuries.

Resident 2's clinical record and charting notes, reviewed from 01/01/22 through 04/25/22, revealed the following:

a. On 01/13/22 and 01/19/22, the resident sustained skin injuries. Documentation indicated the facility treated the injuries and initiated monitoring. However, the record revealed no documented monitoring of the wounds at least weekly until resolved.

b. The resident fell on 02/01/22. Review of the record revealed no documented evidence the facility monitored and documented on the progress of the resident's condition at least weekly until resolved.

The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed on 04/27/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had a significant change of condition were evaluated, referred to the RN for an assessment and the service plan updated as needed for 1 of 1 sampled resident (#1), failed to monitor and document weekly progress of short-term changes of condition until the conditions resolved, and monitor the effectiveness of interventions developed for 1 of 3 sampled residents (#2). Resident 1 experienced an overall health decline and multiple falls with injuries which lacked monitoring of fall interventions for effectiveness and referral to the RN when appropriate. Resident 1 continued to decline in health status and injury falls. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 10/2019 with diagnoses including vascular dementia and had a history of falls.

Resident 1's progress notes, dated 01/13/22 through 04/26/22, service plan dated 01/19/22, with hand-written updates on 02/04/22, 02/09/22 and 03/03/22, additional temporary care plans, significant change of condition evaluation dated 04/08/22 and incident reports were reviewed.

a. The following fall interventions were documented in the resident's 01/19/22 service plan:

* Keep pathways clear;

* Reminders to use front wheel walker;

* Regular medication review to prevent falls;

* Two hour safety checks during night shift; and

* Complete quarterly fall assessment.

Between 01/13/22 and 04/26/22 the resident experienced the following falls with injuries:

* On 01/21/22, Resident 1 was "on alert for fall and injuries [fall on 01/13/22], wound on nose is scabbed. Forehead wound cleansed and covered";

* On 03/29/22 at 3:45 am, Resident 1 was found on floor in apartment with bruising to right elbow and left side of back;

* On 04/05/22 at 3:40 am, Resident 1 was found on the floor with bruising to the head/forehead;

* On 04/07/22 Resident 1 had an injury fall in apartment doorway at 4:00 am with laceration on back of head, resident sent to hospital;

* On 04/14/22 at 1:45 am the resident was found on floor in apartment. Resident had skin tears on left arm by the elbow and forearm. Resident was lethargic after the fall. Resident stated s/he hit his/her head and paramedics transferred the resident to the hospital. Resident 1 returned to the facility on 04/18/22 at 1:32 pm.

* On 04/18/22 at 2:00 pm, the resident had a non-injury fall.

* On 04/21/22 at 4:00 pm, the resident had a fall and hit his/her head on metal bed frame.

There was no documented evidence the facility reviewed and monitored fall interventions for effectiveness, developed and implemented new fall interventions for any of the falls that occurred between 01/13/22 and 04/26/22 to prevent further injury falls.

During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the pattern of falls was a change in the resident's current status. Staff 3 acknowledged the lack of an evaluation for the pattern of falls and the lack of referral to the RN for assessment.

There was no documented evidence the facility evaluated the falls in relation to the resident's condition, referred to the RN for assessment and updated the service plan after the significant change of condition.

The failure of the facility to evaluate the resident, review previous fall interventions for effectiveness and develop new interventions to prevent future falls placed the resident at risk for continued falls and injuries.  

The need to ensure the facility had a system in place to evaluate the resident's changes in condition and refer to the RN when appropriate was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

b. Between 01/13/22 and 04/26/22 the resident was hospitalized on five occasions, experienced increased confusion, disorientation, an increase in his/her ADL care needs, and an overall decline in his/her condition. This represented a significant change of condition that required an evaluation and referral to the RN for assessment.

There was no documentation that the RN was notified of the resident's changes in condition and health status.

During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the resident's change of condition was triggered on 03/19/22, however, an evaluation wasn't completed and the RN wasn't notified. Staff 3 indicated she wasn't aware of the resident's change in condition and acknowledged the lack of an evaluation, RN assessment and an update to the service plan.

The need to ensure the facility had a system in place to evaluate the resident's changes in condition and refer to the RN when appropriate was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

1). Comprehensive RN assessments have been completed for the identified residents.

2). Staff have received additional instruction/direction regarding changes of conditions and what must be reported to the RN.   Letter of agreement for RN in place for improvement of professional oversight.

3). Resident conditions are reviewed weekly with the interdisciplinary team for RN notification.

4). Administrative Team to assure compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure the RN conducted an assessment of the resident's significant change of condition which documented findings, resident status and interventions made as a result of the assessment for 1 of 1 sampled resident (#1). Resident 1 experienced an overall health decline, a pattern of falls with injuries and a hospice admission which lacked an RN assessment. Resident 1 continued to experience injury falls. Findings include, but are not limited to:

Resident 1's progress notes, dated 01/13/22 through 04/26/22, service plan dated 01/19/22, with hand-written updates on 02/04/22, 02/09/22 and 03/03/22, additional temporary care plans, significant change of condition evaluation dated 04/08/22 and incident reports were reviewed.

a. The following fall interventions were documented in the resident's 01/19/22 service plan:

* Keep pathways clear;

* Reminders to use front wheel walker;

* Regular medication review to prevent falls;

* Two hour safety checks during night shift; and

* Complete quarterly fall assessment.

Between 01/13/22 and 04/26/22 the resident experienced seven falls with injuries.

The pattern of falls was a change in the resident's current status and represented a significant change of condition for which an RN assessment was required.

There was no documented evidence the facility RN completed an assessment of the resident's significant change of condition with documented findings, resident status and interventions made as a result of the assessment.

During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the pattern of falls was a change in the resident's current status and required an RN assessment.

The failure to ensure the RN conducted an assessment of the resident's significant change of condition with documented findings, resident status and interventions made as a result of the assessment resulted in continued injury falls.

The need to ensure the facility RN assessed all significant changes of condition was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

Refer to C 270, Example 1a

b. Between 01/13/22 and 04/26/22 the resident was hospitalized on five occasions, experienced increased confusion, disorientation, increase in his/her ADL care needs, an overall decline in his/her condition and was admitted to hospice. This represented a significant change of condition that required an RN assessment which documented findings, resident status and interventions made as a result of the assessment.

There was no documentation of an RN assessment which documented findings, resident status and interventions made as a result of the assessment.

During an interview on 04/26/22 with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director), they acknowledged the multiple hospitalizations, changes in cognition and ADL care needs and admission to hospice represented a significant change of condition which required an RN assessment.

The need to ensure the facility RN assessed all significant changes of condition was discussed with Staff 1, Staff 2 and Staff 3 on 04/27/22. They acknowledged the findings.

1). A comprehensive significant change of condition for the identified resident has been completed by the RN Consultant.  

2). Staff have received additional instruction/direction regarding changes of conditions and reportable items to the RN.   Letter of agreement for RN in place for improvement of professional oversight.

3). Resident conditions are reviewed weekly with the interdisciplinary team for RN notification.

4). Administrative Team to assure compliance.  

Based on observation, 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 04/25/22 through 04/27/22, 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 302: Systems: Tracking Controlled Substances;

C 303: Systems: Medication and Treatment Orders;

C 305: Systems: Resident Right to Refuse;

C 310: Systems: Medication Administration; and

C 325: Systems: Self-Administration of Medication.

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 04/27/22.

Refer to C 302, C 303, C 305, C 310, and C 325.

Based on observation, interview and record review, it was determined the facility failed to ensure a system was in place for accurately tracking controlled substances administered by the facility for 1 of 1 sampled resident (#2) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:

Resident 2 admitted to the facility in September 2019 with diagnoses of Type 2 Diabetes and hypertension.

The resident's record, including the MARs between 03/01/22 and  04/25/22 and the Controlled Substance Disposition logs were reviewed during the survey.

* Between 03/01/22 and 04/25/22, there were four instances that the documentation on the MARs and the Controlled Substance Disposition log did not match for administration of oxycodone 5 mg tablets; and

* On 03/03/22, 04/04/22, 04/05/22 and 04/07/22, the medication was signed out on the Controlled Substance Disposition log but was not documented as given on the MAR.

The need to ensure a system was in place for accurately tracking controlled substances administered by the facility was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.

1). The identified discrepancies have been corrected.  

2). Periodic, random sampling between the MAR and the narcotic ledger is in place to identify future discrepancies.

3). Sample findings are immediately reviewed with staff as needed and are further reviewed in QAPI meetings.

4). Administrative Team to assure compliance.  

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

1. Resident 2 moved into the facility in 2019 with diagnoses including insulin dependent diabetes.

Physician orders and MARs for Resident 2, reviewed from 04/01/22 - 04/25/22, revealed the following orders were not followed:

a. Lantus 26 units daily at bedtime was not given on 04/04/22, 04/09/22 and 04/12/22. Additionally, no CBG was documented. Staff circled their initials indicating the insulin was not administered. However, the reason why it was not given was unclear.

b. Victoza 1.8 mg (injectable diabetic medication) was not given on 04/09/22 and 04/12/22. Staff circled their initials indicating the medication was not administered. However, the reason why it was not given was unclear.

c. Mirtazapine (for depression) 15 mg one tablet at bedtime was not given on 04/08/22. Staff circled their initials indicating the medication was not administered. However, the reason why it was not given was unclear.

d. On 04/08/22 and 04/09/22, the following medications were not administered: Pregabalin (relieves neuropathic pain) 150 mg two capsules daily at bedtime, Rogaine Women's one squirt applied to scalp daily, and Ropinirole (treats restless leg syndrome) 2 mg two tablets daily at bedtime. Staff circled their initials indicating the medications were not given. However, the reason why they were not administered was unclear.

e. Resident 2 had orders for staff to take monthly vital signs. On 04/01/22, staff circled their initials and indicated the vital signs would be taken "tomorrow". There was no further documentation that the vital signs were obtained.

f. Cranberry tablets 200 mg twice daily was not documented as given from 04/18/22 through 04/23/22.

g. On 04/04/21, the following medications were not documented as given: Victoza 1.8 mg injection, Pregabalin 150 mg two capsules, Rogaine Women's Foam application to scalp, Ropinirole 2 mg two tablets, Circaids leg wraps for edema, and Vaseline treatment to legs.  On 04/26/22 at 2:05 pm, the surveyor and Staff 7 (MT) observed/checked the MARs and medication supply. Staff 7 was unable to verify if the above orders had been followed.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22 and 04/27/22. They acknowledged the findings. No further information was provided.

2. Resident 1 moved into the facility in 10/2019 with diagnoses including insulin dependent diabetes.

Hospital discharge orders dated 04/18/22 and the 04/01/22 - 04/26/22 MAR was reviewed and revealed the following order was not followed:

a. Humalog U-100 sliding scale insulin, four times daily (meals and bedtime), at varied amounts based on CBG values was not on the MAR from 04/18/22 - 04/25/22.

Interview on 04/26/22 with Staff 2 (Assistant ED), who was administering medications on 04/26/22, confirmed the resident was not receiving the sliding scale insulin from 04/18/22 through 04/26/22. Staff 2 indicated the facility changed from Quick MAR to Alis MAR system and the sliding scale had not been transcribed on the Alis MAR. Staff 2 indicated s/he would follow up and confirm the sliding scale orders.

On 04/26/22 surveyor and Staff 7 (MT) reviewed the electronic MAR. The sliding scale insulin was added back on the MAR and the resident had received the sliding scale insulin as of 04/26/22.

The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22. They acknowledged the findings.

1). Identified deficient documentation for both identified residents has been corrected to the extent possible.  Note: due to staff attrition, not all deficient documentation has been recovered.

2). All applicable staff have received additional intensive training regarding standards of practice as it relates to valid documentation.  

3). Random sampling of documentation is completed several times monthly to identify further training needs and to avoid deficient documentation.  Identified deficiencies are addressed at time of identification and further reviewed during QAPI meetings.

4). Administrative Team to assure compliance.  

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 1 of 1 sampled resident (#2) who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 2's MARs were reviewed for the time period of 04/01/22 through 04/25/22.

Staff documented Resident 2 refused:

* Rogaine Women's Hair Foam (for hair growth) on one occasion;

* Circaids leg wraps (to control edema) on one occasion;

* Vaseline treatment to legs on one occasion; and

* Lidocaine patch (for pain) on five occasions.

There was no documented evidence the facility notified Resident 2's physician of the refusals.

In an interview on 04/27/22, Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) acknowledged there was no documented evidence the facility had notified the physician of the refusals. No further information was provided.

1). The provider for the identified resident has been notified of the noted refusals.  

2). Providers notified of first refusal of each medication/treatment; staff follow provider's preference for all subsequent refusals.

3). Provider notifications to be reviewed monthly by RCC.  Nurse to be notified of the same for potential intervention.

4). Administrative Team to assure ongoing compliance.

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

Resident 2 was admitted to the facility in 2019 with diagnoses which included insulin dependent diabetes.

Residents 2's MARs were reviewed from 04/01/22 through 04/25/22 and the following was noted:

a. Resident 2 had orders for Novolog sliding scale insulin four times a day (meals and bedtime) to be given in varied amounts based on CBG results.

On 04/18/22, the facility switched from a Quick MAR system to an Alis MAR system. The sliding scale was noted on the Quick MAR from 04/01/22 - 04/17/22. However, it was never transcribed onto the new MAR, and there was no documentation that the resident received additional insulin from 04/18/22 - 04/25/22.

In an interview on 04/27/22, Staff 6 (MT) confirmed the sliding scale order was not noted on the current MAR. He added that the insulin was administered, but not documented.

b. In an interview with the resident on 04/26/22, s/he stated s/he was on Novolog sliding scale insulin, Aspart insulin, Lantus insulin and Victoza injectable diabetic medication. S/he said staff checked his/her CBGs and drew up the insulin and Victoza, but s/he administered it.

The MARs did not indicate that the resident self-administered his/her insulin and Victoza.

During interviews on 04/26/22 and 04/27/22 with Staff 3 (Health Services Director), Staff 6 (MT) and Staff 7 (MT), they confirmed staff checked the resident's CBGs and drew up the insulin and Victoza, but the resident administered it. Staff 3 reviewed the MAR and acknowledged it was inaccurate.

c. According to the MAR, staff failed to administer the resident's Mirtazapine (for depression) 15 mg one tablet daily on 04/04/22.

On 04/26/22 at 2:05 pm, the surveyor and Staff 7 (MT) observed/checked the MARs and medication supply. Staff 6 verified that the medication had been given, but staff failed to document.

d. S/he had an order for Diclofenac gel to be applied to "affected area 3 times daily as needed for moderate pain." The MAR lacked resident-specific instructions for the application of the gel.

e. The resident had an order for Carbamide ear solution (to treat ear wax). Staff were instructed to administer 1-5 drops into both ears twice daily PRN. The MAR lacked specific parameters indicating circumstances that warranted how many drops were to be given.

The need for the facility to ensure MARs were accurate and provided clear instruction to unlicensed staff was discussed with Staff 1 (ED), Staff 2 (Assistant ED) and Staff 3 (Health Service Director) on 04/26/22 and 04/27/22. They acknowledged the findings. No further information was provided.

1). The identified missing orders/parameters are included in the MAR.

2). All orders for all residents have been reviewed and accurately reflect provider orders.  Parameters for PRN medications are included for those residents unable to direct use within instructions given by provider.  A triple-check system is in place for review of all orders as received.

3). Orders are reviewed when received and at least quarterly.

4). Administrative Team to assure compliance.  

Based on interview and record review, it was determined the facility failed to evaluate the resident's ability to safely self-administer medication/treatment upon move-in and at least quarterly and obtained a physician or other legally recognized practitioner's written order of approval for self-administration of medication for 2 of 2 sampled residents (#s 2 and 3) who self-administered medications or treatments. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 2019 with diagnoses which included Type 2 Diabetes.

During an Interview on 04/25/22 at 9:30 am, Resident 2 stated that s/he administered his/her own insulin.

During an interview on 04/26/22 at 2:30 pm, Staff 7 (MT) reported staff set up the insulin for Resident 2, then the resident injected his/her own insulin.

There was no documented evidence the facility evaluated Resident 2's ability to safely self-administer the medication and there was no physician's written order of approval for self-administration of the medication.

The need to ensure the facility evaluated the resident's ability to safely self-administer medication upon move-in and at least quarterly, and obtain a physician or other legally recognized practitioner's written order of approval for self-administration of medication was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.

2. Resident 3 was admitted to the facility in March 2022.

During an interview on 04/25/22 at 1:00 pm, Resident 3 stated that s/he self-administered Warfarin (blood thinner).

There was no documented evidence the facility evaluated Resident 3's ability to safely administer his/her own medication, and there was no physician's written order of approval for self-administration of the medication.

The need to ensure the facility evaluated the resident's ability to safely self-administer medication upon move-in and at least quarterly, and obtained a physician or other legally recognized practitioner's written order of approval for self-administration of medication was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.

1). Identified residents have been evaluated for ability to self-administer identified medications.  Provider orders are in place for both identified residents.

2). Residents who desire to participate in self-medication are identified prior to move-in and as needed.  When identified, residents are evaluated and if deemed appropriate to proceed, a provider's order permitting is obtained.  

3). Self-medication safety is evaluated at least quarterly.

4). Administrative Team to assure compliance.  

Based on observation, interview and record review, it was determined the facility failed to ensure an assessment by a PT, OT or RN was completed at least quarterly for assistive devices with potentially restraining qualities for 2 of 2 sampled residents (#s 1 and 2) who had supportive devices. Findings include, but are not limited to:

1. Resident 2 admitted to the facility in 2019.

The resident's service plan dated 01/24/22 indicated use of ¼ side rails on the bed for stability and positioning.

During an interview with Resident 2 on 04/26/22 at 9:30 am, side rails were observed in a down position on both sides of the bed. Resident 2 stated s/he used the side rails to help with positioning when s/he was in bed.

There was no documented evidence the facility registered nurse, a physical therapist or occupational therapist had conducted an assessment of the use of the ¼ side rails.

The need to complete assessments of supportive devices with restraining qualities was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/27/22 at 10:15 am. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 10/2019 with diagnosis including vascular dementia.

The resident's service plan dated 01/19/22, temporary care plans, observations and interviews with staff were conducted during the survey.

During an interview with Resident 1 on 04/26/22 at 11:08 am, 1/4 length bilateral side rails were observed at the head of the bed and in the up position while the resident was lying in bed. Resident 1 had garbled speech with difficulty communicating complete sentences, however Resident 1 repeatedly said "this thing, this thing" while hitting his/her hand against the bed rail.

There was no documented evidence the facility RN, PT or OT had conducted an assessment and the facility failed to document the following:

* The resident specifically requested or approved of the device and the facility had informed the individual of the risks and benefits associated with the device;

* The facility documented other less restrictive alternatives evaluated prior to the use of the device;

* The facility instructed caregivers on the correct use and precautions related to use of the device; and

* Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis.

The need to ensure supportive devices with restraining qualities were assessed by an RN, PT, or OT and the use of the side rails was documented in the resident's service plan was discussed with Staff 1 (ED), Staff 2 (Assistant ED), and Staff 3 (Health Services Director) on 04/26/22 12:30 pm. They acknowledged the findings.

1). The siderail assessment for resident #2 was located, updated, and placed within the record.  The siderails for resident #1 came with the hospice bed and were subsequently removed during the survey based on resident request and lack of need.

2). Assessments for assistive devices with potentially restraining qualities have been reviewed and updated for all residents utilizing such devices.  These assessments are reviewed at least quarterly.  

3). Compliance related to completion of assessments/reviews is completed at least quarterly in QAPI meeting.

4). Administrative Team to assure compliance.  

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing care to residents for 1 of 3 newly hired direct care staff (# 9) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 04/26/22.

Staff 9 (MT), hired 01/03/22, lacked documented evidence pre-service dementia training was completed prior to performing job duties.

The need for staff to complete all required pre-service dementia training before working with residents was reviewed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the findings.

1). The missing training records have been retrieved and are located within the identified staff member's record.

2). All staff records have been audited to assure pre-service dementia training records are in place.  Records for newly hired staff are continually reviewed during onboarding to assure required documents are completed timely and present.

3). Staff records are reviewed at least quarterly with findings discussed during QAPI.

4). Executive Director to assure compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 9, 10 and 11) completed all required training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 04/26/22. The following deficiencies were identified:

1. Staff 9 (MT), hired on 01/03/22 and Staff 10 (MT), hired on 01/22/22, lacked documented evidence of demonstrated competency in all required areas within 30 days of hire including:

* 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;

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

* General food safety, serving and sanitation; and

* Other duties as applicable (medication administration).

2. Staff 9 and 10 lacked documented evidence of having completed First Aid and abdominal thrust training within 30 days of hire.

3.  Staff 11 (CG), hired on 03/08/22, lacked documented evidence of having demonstrated competency in the following areas:

* Providing assistance with ADL's;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

The need to ensure newly hired direct care staff completed First Aid and abdominal thrust training and demonstrated competency in all required training topics within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the lack of training documentation.

1). All identified staff records contain evidence of completion of the training topics required within 30 days of hire.  

2). All staff records have been audited to assure newly hired direct care staff have completed First Aid and abdominal thrust training and demonstrated competency in all required training topics within 30 days of hire.  Records for newly hired staff are continually reviewed during the hire-on process to assure required documents are completed timely.

3). Staff records are reviewed at least quarterly with findings discussed and/or addressed during QAPI.

4). Executive Director to assure compliance.

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

Fire drill and life safety records were reviewed on 04/25/22. The facility failed to evacuate and/or relocate residents during monthly fire drills. Therefore, documentation was incomplete in the following areas:

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

In an interview on 04/25/22 at 2:54 pm, Staff 5 (Dining Service Director), who was the former Maintenance Director, acknowledged the facility failed to evacuate residents and to complete documentation related to the evacuation of residents.

The requirements for conducting fire drills and maintaining completed fire drill records was discussed with Staff 1 (ED) on 04/27/22. She acknowledged the findings.

1). Monthly fire drill documentation now includes evidence of problems encountered, comments relating to residents who resisted or failed to participate in the drills, evacuation time-period needed, and number of occupants evacuated.  

2). A Maintenance Director has been retained and has received training related to the specific fire drill documentation requirements and frequency.  

3). Fire drill documentation is reviewed in detail on a monthly basis following each drill for content.  Audit findings and any concerns related to fire drill participation is reviewed during the quarterly QAPI meeting.

4). Maintenance Director and Executive Director to assure compliance.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents 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. Findings include, but are not limited to:

On 04/26/22, Staff 1 (ED) was asked to explain the facility's process and provide documentation for instructing residents in fire and life safety procedures upon admission and annually. Staff 1 was unable to provide a clear description of their process for training residents in fire and life safety procedures and was unable to provide any supporting documentation related to the completion of the required training's.

The need to instruct residents upon move-in and annually in general fire safety procedures was discussed with Staff 1 on 04/27/22.  She acknowledged the findings.  

1). General safety procedures, evacuation methods, and resident responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an acutal fire are included in the Resident Handbook which is provided to each resident prior to move-in.  The signature page indicating acknowledgement by the resident is included in each resident's business record. Evidence of annual or more frequent retraining of residents regarding fire and life safety is located on monthly fire drill records.

2). All residents are trained to fire and life safety to the extent possible based on cognition.  Evacuation needs are reflected on individual service plans and re-evaluated at least quarterly and/or with any significant change of condition.

3). Training for residents related to fire and life safety is reviewed quarterly during QAPI.

4). Maintenance Director and Executive Director to assure compliance.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:

The exterior grounds were toured on 04/25/22 at 1:03 pm. There were drop-offs of up to two inches from the pavement to the planting bed at the corners and along the edges of multiple pathways around the perimeter of the building. These drop-offs created potential tripping or fall hazards for residents.

On 04/27/22 at 10:45 am, the surveyor showed Staff 1 (ED) and Staff 2 (Assistant ED) the drop-offs. They acknowledged the findings.

1). Trip hazards identified during the survey have been eliminated.  

2). Monthly auditing of exterior pathways is completed by the Maintenance Director to prevent future potential hazards.

3). Monthly audits with results will be reviewed at least quarterly during QAPI.

4). Maintenance Director and Executive Director to assure compliance.

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

The interior and exterior of the building were toured on 04/25/22 at 11:07 am. The following areas needed cleaning or repair:

* Wooden door trim surrounding resident rooms 203, 204, 209, 211, 212, 216, 217, 301, 306 and 308 had gouges with exposed bare wood;

* The rubber door seal was coming off resident room 306's door;

* Carpet at the entry to resident room 215 was starting to fray, creating a potential tripping hazard;

* Sections of the hallway handrails near rooms 104,106 and 215 had protruding hardware and/or were not connected, leaving a rough surface;

* The area above the fireplace was coated in black residue;

* Exit doors in the laundry room and at the end of the 300 hall had black streaks across lower portion of the doors;

* Laundry machines had pink and brown buildup around the bleach compartments;

* The area behind the dryers was covered in lint and dust;

* The area behind the soda machine in laundry room was covered in dust; and

* The outside dryer vent was not covered leading to lint buildup on the pavement in the courtyard.  

The areas needing cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 2 (Assistant ED) on 04/27/22 at 10:45 am. They acknowledged the findings.

1). All interior/exterior areas identified during the survey have been remedied.

2). Environmental audits are performed routinely by the Maintenance Director.  All staff and capable residents have been resensitized to the importance of reporting concerns.

3). Regional Director will perform quarterly environmental audits to monitor for any ongoing needs not otherwise identified.

4). Maintenance Director and Executive Director to assure compliance.

Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a washing machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:

During a tour of the community laundry room on 04/25/22 at 11:35 am, it was observed that there were three residential washing machines present.

In an interview with Staff 11 (CG) on 04/25/22 at 3:04 pm, she stated that soiled linen was double bagged, brought to the hopper room, rinsed in the hopper sink and then washed with laundry detergent in the residential washing machines. Staff 11 then confirmed that soiled linens were washed without the use of a chemical disinfectant or a 140 degree Fahrenheit hot water rinse.  

In an interview with Staff 1 (ED) on 04/27/22, she confirmed that the facility did not use a hot water rinse or a chemical disinfectant when laundering soiled linens.

The facility's failure to properly launder soiled clothing and linens was reviewed with Staff 1 and Staff 2 (Assistant ED) on 04/27/22. They acknowledged these findings.

1). Due to the configuration of the community hot water system, a chemical disinfectant is now in use.

2). To prevent future concerns, the community will continue to utilize a chemical disinfectant while washing laundry.

3). Verification of use of a chemical disinfectant will be randomly audited.

4). Maintenance Director and Executive Director to assure compliance.

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

The building was toured on 04/25/22 at 1:30 pm. An electric wall heater was observed in room 110. When it was turned on and the temperature of the surface of the metal grill was measured with the surveyor's digital thermometer, the temperature was noted to be 160.3 degrees F. In an interview on 04/25/22 at 2:10 pm, Staff 1 (ED) reported there were nine similar one-bedroom rooms that had electric wall heaters.

On 04/27/22, the surveyors visually inspected the wall heaters in each of the nine rooms. Four rooms were not occupied. There were no obstructions that would put residents at risk in four of the other rooms. One resident had his/her bed pushed up against the wall with the wall heater. However, the resident was alert and oriented, understood the risk and stated s/he did not use the wall heater.

The wall heaters that exceeded 120 degrees F were discussed with Staff 1 and Staff 2 (Assistant ED) on 04/27/22. They acknowledged the findings.

1-4). All wall heaters have been disabled and are no longer operable.