Print Inspection: SDXM

The findings of the re-licensure survey, conducted 06/21/22 through 06/23/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 re-visit survey to the re-licensure survey on 06/23/22, conducted 10/05/22, 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 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

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 06/23/2022, conducted 01/19/23 through 01/20/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-00. Findings include, but are not limited to:

The facility had 39 residents. The facility consisted of three floors with resident rooms located on the second and third floor and a main kitchen included a commercial dishwasher, where all food was prepared. There were two small kitchenettes, second floor and third floor, from which the meals on the memory care units were served. Each kitchenette included a combination refrigerator/freezer, microwave and non-commercial dishwasher.

1. Non-commercial dishwashers were located in the kitchenettes on the second and third floor. The non-commercial dishwashers were observed being used during the survey.  During an interview on 06/22/22, Staff 12 (Food Service Director) confirmed caregiving staff used the non-commercial dishwasher to clean cups and other utensils.

On 06/22/22, the above finding was shared with Staff 1 (ED) and Staff 12 and the staff were directed to use the commercial dishwasher to wash all cups and utensils instead of using the non-commercial dishwashers. Staff acknowledged the findings.

2a. On 06/22/22 at 11:45 am, Staff 13 (Food Service Director B) was observed and the following was noted:  

* Staff 13 prepared a cake dessert with plastic gloved hands;

* During the preparation of the cake dessert, Staff 13 walked away from the tray line and went to the food cart, relocated the cart by touching the handle and top of the food cart with the gloved hands;

* Staff 13 went back to the tray line without changing gloves or washing her hands;

* Staff 13 was observed touching sliced cake dessert with the same gloved hands; and

* The surveyor directed Staff 13 to change gloves during the dessert preparation.

On 06/22/22 between 12:15 pm and 12:30 pm, Staff 9 (RCC) and Staff 16 (Caregiver)  were observed and the following was noted:  

b. Staff 9 was observed with plastic gloved hands preparing to serve an onion beef patty.  Staff 9 cut the beef patty with a bread knife. She then put the bread knife on the countertop where staff put binders. Staff 9 then used the same bread knife to cut another onion beef patty.

c. Staff 16 was observed with plastic gloved hands on the third floor, preparing to serve an onion beef patty and cut the beef patty with a bread knife.  She then put the bread knife on the countertop where staff put binders. Staff 16 used the same bread knife to cut another onion beef patty.

On 06/22/22 at 12:45 pm, the observation was shared and infection control practice was discussed with Staff 12.  They acknowledged the findings.

3a. On 06/21/22 and 06/22/22, during the main kitchen tour, the following was observed to be in need of cleaning or repair:

* Walls near the dishwasher, had spillage and brown matter;

* The floor near the dishwasher area, had a thick layer of black matter build-up;

* The ice maker lid and front on the ice machine was sticky to the touch;

* The ceiling, near the vents and refrigerators, had layers of dust;

* Front and side towel dispenser was sticky to the touch;

* Caulking around the window had rusted; and

* The ceiling vent had accumulated dust.

b. On 06/21/22 and 06/22/22, during the kitchenette tour on the second floor, the following areas were observed to be in need of cleaning or repair:  

* Inside and outside of the microwave had dried food matter and was sticky;

* Evidence of eaten cake was inside microwave including a metal fork;

* An open bottle of a sport drink without a lid on, stored on the top cabinet shelf;

* An opened snack bag stored on top of the cabinet shelf; and

* Unfinished kitchenette door frame, with dried on food matter.

c. On 06/21/22 and 06/22/22, during a kitchenette tour on the third floor, the following areas were observed to be in need of cleaning or repair:  

* Wall, near a trash can, had chips in multiple areas;

* Kitchenette door frame had splatters and dried food matter; and

* Black stain inside cabinet where a bottle of syrup was located.

On 06/21/22 and 06/22/22, the main kitchen and kitchenettes were toured with Staff 1 and Staff 12. Staff acknowledged the areas needed cleaning and repair.

1.

      1.  All dishware and utensils will be brought to the main kitchen for cleaning after each meal.

     2.  All staff to be inserviced on Infection Control practices including food prep.  

       3.  All areas identified to be cleaned in the main kitchen as well as the kitchenette areas.

       4.  All areas identified in need of maintenance to be fixed.

2.  Audits to be conducted to check on infection control during meal prep and meal service on the different floors.  Maintenance to do weekly rounds of identified areas to assure ongoing compliance. Administrator or designee to do weekly rounds of facility to identify areas to be cleaned.

3.  Weekly rounds to be initiated.  Documentation of these rounds to be brought to the quarterly QA meeting.

4.  Administrator or Designee to be responsible for monitoring this system.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 3) whose move-in evaluations were reviewed. Findings include, but are not limited to:

1. Resident 3 moved into the facility in 06/2022.

The new move-in evaluation failed to address the following elements:

* Physical health status including visits to health practitioner(s) ER, hospital or NF in the past year;

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

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

* Independent activity of daily living including transportation;

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

* Emergency evacuation ability;

* History of dehydration or unexpected weight loss or gain;

* Smoking status; and

* Alcohol and drug use.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) on 06/23/22. Staff acknowledged the findings.

2. Resident 1 moved into the facility in 06/2022.

The new move-in evaluation failed to address the following elements:

* Emergency evacuation ability.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (ED) on 06/23/22. Staff acknowledged the findings.

?1.  Residents 1 and 3 will have service plan updated to reflect areas that were missing.

2.  Nurse consultant to inservice all managers responsible for move in evaluations for comprehensive person centered service plans.

3.  Nurse consultant to review all new service plans upon move in.

4.  Administrator or Designee to be responsible for completing this system and communicating with the nurse consultant on all new move ins.

Based on observations, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#4) who experienced a significant change of condition related to weight loss. Findings include, but are not limited to:

Resident 4 was admitted to the facility in March 2016 with diagnoses including dementia.

Weight records dated 12/06/21 through 06/05/22 were reviewed and indicated the resident experienced a 6.79 pound unplanned weight loss between 12/06/21 and 01/06/22.

Resident 4's weight record noted the following:

* 12/06/21 at 154.4 lbs; and

* 01/06/22 at 144 lbs.

Between 12/2021 and 01/06/22 Resident 4 lost 10.4 pounds or 6.79% of his/her bodyweight.   The loss of over 5% of body weight in one month constituted a significant change of condition for severe weight loss.

Resident 4 was on palliative care and continued to lose weight but had not experienced a significant or severe weight loss since 01/2022.

A progress note dated 01/11/22 stated the previous facility RN was aware of the weight loss. The facility failed to ensure an RN assessment was completed with documented findings, resident status and interventions made as a result of the assessment.

Multiple observations of the resident between 06/21/22 and 06/23/33 showed the resident required one on one meal assistance with every meal.

In an interview on 06/22/22, Staff 10 (CG) stated s/he was aware of the weight loss. The resident was on a pureed diet with one on one meal assistance, drank nectar thick liquids and received a supplemental shake two times daily.

The need to ensure an RN assessment was completed which included the required components of documented findings, resident status and interventions made as a result of the assessment was discussed in interview on 06/22/22 with Staff 2 (RN). Staff 2 noted the previous RN's assessment was not complete.

During an interview on 06/23/22, Staff 1 (Executive Director) and Staff 2 acknowledged the findings.

1.  Resident 4 no longer living in the community.

2.  Staff associated with this citation no longer employed in the community.  Nurse consultant to review all weight loss in the community to identify any needs for RN assessments.

3.  Monthly reviews to be conducted by RN consultant or designee to assure timely assessments are completed.

4.  Administrator or designee will compile all monthly weight reviews conducted and bring to quarterly QA meeting.  

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 1 of 1 sampled resident (# 6) reviewed for significant changes of condition. This is a repeat citation. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 03/2022 with diagnoses including dementia.

Interviews with staff on 10/05/22, a review of the current service plan with updates through 10/05/22, and review of the progress notes dated 08/03/22 through 10/5/22 indicated the following significant change of condition:

A progress note dated 08/27/22 included Resident 6 had been sent out to the hospital for being dizzy, off-balance and was found on the floor.

S/he returned from the hospital on 09/12/22 with the following changes in his/her condition:

* Placement of a catheter;

* Need of a wheelchair for ambulation;

* Use of a Hoyer lift; and

* On 09/13/22 was admitted to hospice services.

Staff 21 (Director of Operations) and Staff 4 (Business Office Manager) stated in interview on 10/05/22, that an RN assessment of the significant change of condition could not be found.

The need to ensure an RN assesses significant changes of condition was discussed with Staff 1 (Administrator) on 10/05/22. She acknowledged the findings, and no further documentation was provided.

1. In service will be performed with facility RN to go over RN assessments and licensing rul;es for RCF facilities in relation to resident assessments and changes of conditions.

2. Executive Director and RN will have weekly meetings to go over all resident changes, what assessments need to be done, and which ones have been completed.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 06/21/22, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2's MARs, reviewed from 06/01/22 through 06/21/22, revealed the following:

* The resident received Lispro (insulin to treat diabetes) three times daily, Lantus (insulin to treat diabetes) once daily and Trulicity (an injectable medication to treat type II diabetes) weekly; and

* The insulin had been given by Staff 9 (RCC) and Staff 19 (MT) on multiple occasions.

Staff 9 (RCC) and 19's (MT) transfer of delegation for insulin injection task and the Trulicity injectable medication was completed on 02/21/22. The current facility RN accepted the outgoing RN's plan for supervision of Staff 9 and 19.

1. The periodic re-evaluation of insulin injection delegation task for Staff 9 and 19 completed 04/21/22 and 03/10/22 and lacked documentation in the following areas:

* There was no documented evidence Staff 9 and 19's skills, abilities and willingness for the delegation tasks; and

* There was no rational, based on the competency of the unlicensed staff, for how frequently the unlicensed staff should be supervised and reevaluated.

2. Staff 9 and 19 documented on the 06/01/22 through 06/21/22 MAR that Staff 9 administered Resident 2's Trulicity injection on 06/03/22 and Staff 9 administered the injection 06/17/22 to the resident.

The initial evaluation of the Trulicity injectable medication for Staff 9 and 19's skills and ability was completed on 03/10/22 and scheduled for re-evaluation in 60 days which was approximately on 05/10/22. There was no documented evidence the facility RN re-evaluated Staff 9 and 19's skills and ability as of 06/22/22.

3. Staff 20's (MT) transfer of delegation for insulin injection task was completed on 02/21/22. The current facility RN accepted the outgoing RN's plan for supervision of Staff 20.

Staff 20 documented on the 06/04/22 through 06/21/22 MAR that she administered Resident 2's insulin injection on multiple occasions.

The last evaluation of the insulin injection for Staff 20's skills and ability was completed on 12/04/21 and scheduled for re-evaluation in 180 days which approximately on 06/04/22. There was no documented evidence the facility RN re-evaluated Staff 20's skills and ability as of 06/22/22.

On 06/22/22, the need to ensure all staff who administered insulin injections were appropriately delegated and documented in accordance with OSBN Administrative Rules was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

1.All delegations to be reviewed by RN consultant to assure proper timelines are being adhered to.  Any employee identified in need of having their delegation updated to occur at this time.  

2.Calendar to be established to assure all timelines moving forward are adhered to.  

3.Monthly Administrator and RN consultant to review any staff member in need of updating delegation.

Administrator or Designee to bring calendar to monthly QA to assure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure Fire drills were conducted in accordance with Oregon Fire Code including complete written fire drill records.  Findings include, but are not limited to:

Fire drill and fire and life safety training records were reviewed with Staff 5 (Maintenance Director) on 06/22/22 at 1:20 pm. The fire drill records from 12/2021 and 05/2022 identified the following information was not documented:

* Number of occupants evacuated; and

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills.

The requirements for documenting fire drills was reviewed with Staff 1 (Executive Director) and Staff 17 (Owner/CEO) on 06/22/22. They acknowledged the findings.

1.Administrator and Maintenance Director have updated Fire Drill form to include issues identified.

2.Utilizing the new form, all components associated with a Fire Drill should be accomplished and documented.

3.This new form to be brought to QA monthly.

Administrator or Designee to assure this is completed on the new form monthly and Administrator to sign off on this form.?????

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 C280

1. In service will be performed with facility RN to go over RN assessments and licensing rul;es for RCF facilities in relation to resident assessments and changes of conditions

2. Executive Director and RN will have weekly meetings to go over all resident changes, what assessments need to be done, and which ones have been completed.

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

Refer to C 240 and C 420.

Refer to C240 and C420

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

Refer to C 252, C 280 and C 282.

Refer to C252, C280, and C282

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

Refer to C280

1. In service will be performed with facility RN to go over RN assessments and licensing rul;es for RCF facilities in relation to resident assessments and changes of conditions.

2. Executive Director and RN will have weekly meetings to go over all resident changes, what assessments need to be done, and which ones have been completed.

Based on observation, interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 1 of 4 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia.

During the survey, Resident 3 was observed to have lunch in the dining room independently. The resident was easily distracted during the meal and was not able to focus on the meal.

Resident 3's meal intake monitor record from 06/01/22 to 06/22/22 was reviewed and revealed the following:

* There were multiple blanks on the record; and

* There were eight occasions the resident consumed less than 50 % of breakfast, seven occasions for lunch and 10 occasions for dinner.

Resident 3's service plan, dated 05/31/22, indicated to allow enough time to eat at a comfortable place. Staff were to encourage and provide nutritious snacks if the resident did not have adequate intake at meals. However, the service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences and need for increased fluids.

The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED) on 06/23/22. She acknowledged the findings.

1.Resident 3 to have meal monitor reviewed weekly for accuracy of charting.  This is to be done by Resident Care Coordinator or designee.  Administrator to look at and update service plan related to nutrition and hydration.

2.Administrator, Resident Care Coordinator, and Dietary manager to review meal monitor together monthly to identify any necessary changes.  

3.This will be evaluated weekly.  Resident Care Coordinator to be inserviced  on identifying issues and bringing them to Administrator's attention in between their monthly meetings.

Resident Care Coordinator or designee to be responsible for completion and bringing identified issues to QA monthly.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 2 of 4 sampled residents (#s 1 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Residents 1 and 3 moved into the facility in 06/22 with diagnoses including dementia. There was no documented evidence an activity evaluation had been completed and individualized activity plans developed including:

* Residents' past and current interests;

* Current abilities and skills;

* Emotional/social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate in activities; and

* Identified activities for behavior interventions.

There were no specific activity plans which detailed what, when, how, and how often staff should offer and assist either resident with individualized activities.

On 06/23/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Executive Director) and Staff 3 (Life Enrichment Director). They acknowledged the findings.

1.Administrator and Activity Director to review Resident 1 and 3 to have Activity portion of service plan updated to provide person centered care.?

2.Administrator to review all new move in service plans once completed by Activity Director.???

3.This will be evaluated quarterly through the service plan review process.

Administrator or designee will be responsible for the oversight of the Activity Director's service plans to ensure accuracy.