Print Inspection: SY0U

The findings of the re-licensure survey conducted 11/15/21 through 11/18/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and 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

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 re-visit to the re-licensure survey of 11/18/21, conducted 03/02/22, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

On 11/15/21 and 11/17/21, the facility's three kitchens, located in Cottages A, B and C, were observed to need cleaning and repair in the following areas:

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

* Metal countertops and shelving units;

* Plastic storage bins;

* Storage shelves in the dry food storage area;

* Flooring underneath metal shelving, stoves, and sinks;

* Doors; and

* Ceiling vents.

b. The following areas needed repair:

* Doors, door frames and storage shelves had areas of chipped paint, gouges, and cracks; and

*Overhead lighting fixtures were cracked in Cottages B and C.

The areas that required cleaning and repair were discussed with Staff 2 (RN) and Staff 3 (Regional Operations Specialist) and observed with Staff 11 (Cook) on 11/17/21. They acknowledged the findings.

1. The kitchens will receive a deep clean. Lighting fixtures will be replaced and chipped paint,

gouges, and cracks will be repaired.

2. The Dining Services Director and Executive Director will receive additional training on Kitchen Cleaning Schedule Policy and Procedure.

3. The Dining Services Director will review weekly per the Quality Assurance Review Schedule - Dining Services.

4. The Executive Director will ensure the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations included all required elements for 1 of 1 sampled resident (#5). Findings include, but are not limited to:

Resident 5 was admitted in 08/2021 with diagnoses including arthritis.

Review of the resident's new move-in evaluation, dated 08/27/21, revealed it failed to include the following required elements:

* Interests, hobbies, social and leisure activities;

* History of treatment and effective non-drug interventions related to mental health;

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

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

The need to ensure new move-in evaluations included all required elements was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings.

1. The Resident Evaluation Tool has been reviewed and updated as needed to include all elements required per the Resident Move-In and Eval: Res Evaluation.

2. The Executive Director, Wellness Director(s) and Wellness Nurse will receive additional training on the Move-In Evaluation Tool.  

3.  The Executive Director will review this area with each move-in.

4.  The Executive Director will ensure the corrections are completed and monitored.   

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and failed to provide clear instruction to staff for the provision of care for 2 of 3 sampled residents (#s 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 11/2019, with diagnoses including Alzheimer's Disease.

Review of Resident 2's service plan, dated 10/22/21, interviews with staff, and observations of the resident revealed the service plan was not reflective of the following:

* Two-person transfers;

* Use of wheelchair for mobility;

* Assistance for bed mobility; and

* Knee brace.

The need to ensure service plans were reflective of the resident's current status was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 05/2021 with diagnoses including vascular dementia and multifocal leukoencephalopathy.

The resident's record, including the most recent service plan (dated 07/27/21), quarterly evaluations dated 08/06/21 and 10/08/21, change of condition evaluation dated 11/09/21, and outside provider notes from 08/20/21 through 09/15/21, were reviewed, observations were made, staff and the resident's private caregiver were interviewed.

A review of Resident 4's 07/27/21 service plan revealed it was not reflective of the resident's current status and care needs or did not provide clear instructions to staff in the following areas:

* Hospice status;

* Catheter flushes;

* Use of protective footwear; and

* Feeding.

There were no interim service plans related to those areas provided for the resident.

The need for service plans to be reflective of residents' current status and care needs and to provide clear direction to staff regarding the provision of care was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1.  The Service Plan for resident #2 and resident #4 were updated to reflect the residents current status and care needs and to provide clear direction to staff.

2.  The Executive Director, Wellness Director(s), and Wellness Nurse will receive additional training on the Service Plan Policy.

3. The service plan schedule will be reviewed weekly per the Quality Assurance - Health Services Review Schedule.

4.  The Executive Director will be responsible for ensuring corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were monitored based on their evaluated needs and short-term changes of condition were monitored to resolution for 2 of 3 sampled residents (#s 2 and 4) who experience short-term changes of condition. Findings include, but are not limited to:   

1. Resident 2 was admitted to the facility in 11/2019, with diagnoses including Alzheimer's Disease.

Review of Resident 2's current service plan, interim service plans, 08/20/21 through 11/14/21 progress notes, fall investigations, and RN assessments revealed the following:

Resident 2 experienced 18 falls between 10/01/21 and 11/11/21. The facility failed to consistently document what fall prevention interventions were in place at the time of the falls and failed to monitor the effectiveness of the interventions.

The need to monitor the effectiveness of fall prevention interventions was discussed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/17/21. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 05/2021 with diagnoses including vascular dementia and multifocal leukoencephalopathy.

The resident's record most recent service plan dated 07/27/21, progress notes from 08/17/21 through 11/15/21, and evaluations were reviewed, observations were made, and staff and the resident's private caregiver were interviewed.

Progress notes identified multiple short-term changes of condition:

*08/25/21, 09/21/21, 10/06/21, and 10/25/21: the resident started an antibiotic; and

*11/09/21, the resident returned from the hospital.

Although the documentation indicated those short-term changes of condition were monitored, there was no documented evidence they were resolved.

The need to monitor short-term changes of condition through resolution was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. The facility has documented the review of effectiveness for fall prevention interventions on resident #2 and has documented the resolution of short term changes of condition for resident #4.

2.  The Executive Director and Wellness Nurse will receive additional training on the Change of Condition Policy and Procedure.

3.  The Wellness Nurse will review this area weekly per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

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 (#3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 11/15/21, Resident 3 was identified as receiving insulin injections by unlicensed facility staff.

A review of Resident 3's delegation records on 11/17/21 identified the following:

a. Resident assessments did not consistently include the following:

* How it was determined his/her condition was stable and predictable; and

* A rationale for how frequently s/he would be re-assessed.

b. Initial delegation documentation for Staff 13 (MT) and Staff 17 (MT) lacked the following:

* A rationale the task could be safely delegated to the caregiver;

* How it was determined the caregiver was competent to safely perform the task;

* A rationale for the frequency the resident would be re-assessed;

* A rationale for the frequency the caregiver would be re-evaluated; and

* An indication the RN took responsibility for delegation tasks and ensured supervision would occur for as long as the RN was supervising performance.

c. Re-delegation documentation for Staff 13 and Staff 17 lacked the following:

* An assessment of the resident which included how it was determined the resident remained stable and predictable;

* Documentation of how it was determined the caregiver remained capable and willing to safely perform the task; and

* A rationale for how frequently the caregiver would be re-evaluated.

d. Staff 13 and Staff 17 were initially delegated by Staff 2 (RN) on 03/09/21 and 03/08/21, respectively. Documentation indicated they would be re-assessed in 180 days /6 months. Records revealed the RN re-evaluated Staff 13 on 06/03/21 and Staff 17 on 06/07/21. OSBN Division 47 states re-delegation must be "within at least 60 days from the initial date of delegation."

In an interview on 11/18/21, the RN indicated she worked at the facility previously, had delegated those two MTs in the past and was familiar with their abilities, and didn't think she needed to re-evaluate them as frequently as staff she had not worked with before.

Delegation records and the need to ensure delegation of special tasks of nursing care were documented in accordance with OSBN Division 47 were reviewed with Staff 1 (Executive Director), Staff 2 (RN), and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. All current delegation records will be reviewed to ensure appropriate documentation including review schedules.

2. The Executive Director and Wellness Nurse will receive additional training on Delegation rules per the OSBN Division 47 rules.

3. The Wellness Nurse will review this area weekly per the Quality Assurance - Clinical Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure physician orders were followed as written for 1 of 5 sampled residents (#3) whose MARs and physician orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2019 with diagnoses including diabetes.

The resident's clinical record was reviewed, including 10/01/21 through 11/15/21 MARs, physician orders, and a medication error report for 10/12/21, and staff were interviewed. The following was identified:

a. During the acuity interview on 11/15/21, Staff 2 (RN) reported the resident had recently been sent to the emergency department because of a medication error.

* Resident 3 was prescribed the following:

* Humalog 100U/ML (insulin), 9 units subcutaneously every morning with breakfast;

*Humalog 100U/ML, on a sliding scale with each meal, based on CBG; and

*Tresiba Flextouch 100U/ML (insulin), 25 units subcutaneously every morning.

On 10/12/21 the resident received 27 units of Humalog instead of the scheduled 27 units of Tresiba. The 27 units of Humalog was in addition to the scheduled 9 units the resident received that morning.

* The resident's blood sugar level dropped as low as 63, which was documented in a progress note on 10/12/21 and the resident was transported to the emergency department for observation.

* Resident 3 returned to the facility from the emergency department on 10/12/21 in the afternoon.

Records indicated the medication error was immediately reported by the MT, was self-reported to the local Adult Protective Services office the same day, and there was no further outcome for the resident.

In an interview on 11/16/21, the RN reported she had provided extra training to the medication technician responsible for the error.

b. The resident was prescribed Humalog 100U/ML with each meal, based on his/her CBG, on the following sliding scale:

- 0-150 = 0 units

- 151-175 = 1 unit;

- 176-200 = 2 units;

- 201-225 = 3 units;

- 226-250 = 4 units;

- 251-275 = 5 units;

- 276-300 = 6 units;

- 301-325 = 7 units;

- 326-350 = 8 units;

- 351-375 = 9 units;

- 376-400 = 10 units;

- 401-425 = 11 units;

- 426-450 = 12 units;

- 451-476 = 13 units;

- 476-500 = 14 units; and

- 501-525 = 15 units.

The MARs indicated the following errors occurred:

* 10/19/21, 7:30 am: CBG 179; 11 units were administered instead of two (2) units.

* 10/24/21, 11:30 am: CBG 195; one (1) unit was administered instead of  two (2) units.

* 10/27/21, 11:30 am: CBG 174; two (2) units were administered instead of one (1) unit.

* 11/04/21, 11:30 am: CBG 200; three (3) units were administered instead of two (2) units.

In an interview on 11/16/21, Staff 1 (Executive Director) and Staff 2 indicated they were unaware of the errors. On 11/17/21 Staff 2 indicated she had provided additional training to the medication technicians responsible for the errors.

The need for physician orders to be followed as written was discussed with Staff 1 and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings and reported additional training would be provided to all medication technicians.

1. The Medication Administration Record for resident #3 was audited with additional training provided to the Med-Tech regarding following sliding scale insulin orders.

2. The Med-Tech's will receive additional training on resident specific parameters regarding sliding scale insulin.

3. The Wellness Director and/or Wellness Nurse will complete MAR audits weekly per the Quality Assurance Review Schedule - Health Services.

4.  The Executive Director will ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternate months from fire drills and to ensure a written fire drill record was maintained and included all required components in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records for May 2020 through October 2021 were reviewed during survey.

a. There was no documented evidence the facility provided fire and life safety instruction to staff on alternate months from fire drills.

b. The following required components were not consistently documented in fire drill records:

* The escape route used; and

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

The need to ensure fire and life safety instruction was provided to staff on alternate months from fire drills and to ensure fire drill records included all required components was discussed with Staff 1 (ED), Staff 3 (Regional Operations Specialist), and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. The community will complete fire drills life safety instruction at least every other month.

2. The Executive Director and Mainteance Director will receive additional training on the Fire Life Safety Training & Drill Flow Chart and the Fire Drill Checklist.

3. The Maintenance Director will review monthly per the Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

Based on interview and record review, it was determined the facility failed to provide evidence that alternating evacuation routes were used during fire drills and residents received annual fire and life safety instruction. Findings include, but are not limited to:

Review of fire and life safety records for May 2020 through October 2021 revealed the facility lacked documented evidence of the following:  

* Alternate exit routes used during fire drills; and

* Annual fire and life safety instruction for residents that included 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.

The need to ensure alternate exit routes were used during fire drills and fire and life safety instruction was provided to residents at least annually was discussed with Staff 1 (ED), Staff 3 (Regional Operations Specialist), and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. All assisted care resident records will be reviewed to ensure completion of the new resident safety orientation checklist has been completed.

2. The Executive Director and Mainteance Director will receive additional training on the New Resident Safety Orientation Checklist and the Fire Life Safety Training & Drill Flowchart.

3. The Maintenance Director will review with each new move-in and annually per the New Resident Checklist and Quality Assurance - Maintenance Review Schedule.

4.  The Executive Director will ensure the corrections are completed and monitored.  

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

A tour of the facility on 11/15/21 and 11/16/21 revealed the following areas were in need of cleaning  and repair:

* Carpets in common areas in all cottages had diffuse stains;

* Multiple resident carpets viewed from the hallway in Cottage C were stained;

* Laundry rooms in all three cottages had an accumulation of dirt, smudges, and trash on the floors; drips on walls behind and at bases of hoppers; holes in drywall; chipped paint on walls and doors; and the laminate counter in Cottage A was cracked;

* Doors and walls throughout the three cottages had chipped paint;

* Multiple coffee tables had exposed wood on the tops;

* Multiple benches had scrapes and exposed wood on the legs; and

* The caulking at the base of Cottage B, Room 8's toilet and shower was cracked.

The environment was toured with Staff 1 (Executive Director) and Staff 21 (Maintenance Director) on 11/17/21. They acknowledged the findings.

1. An internal building inspection will be completed with identified concerns addressed by cleaning or repairing the items.

2. The Executive Director and Maintenance Director will receive additional training on the Quarterly Building Inspection.

3. The Maintenance Director will review the areas monthly and then meet with the Executive Director and review quarterly per the Quality Assurance - Maintenance Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.  

Based on observation and interview, the facility failed to ensure  fireplace doors did not exceed 120 degrees Fahrenheit.  Findings include, but are not limited to:

The environment was toured on 11/17/21 with Staff 1 (Executive Director) and Staff 21 (Maintenance Director). At the time of the tour, the glass doors of the fireplace located in a common resident area in Cottage C measured 122 degrees Fahrenheit with the surveyor's thermometer. The glass doors of the fireplace in the lobby of Cottage B measured 121 degrees on the same date. Staff 21 turned the fireplaces off at that time. Staff 1 stated she would direct staff not to use the fireplaces in any of the cottages until she was able to obtain screens that kept the temperature at a safe level.

The need to ensure fireplace doors did not exceed 120 degrees Fahrenheit was discussed with Staff 1 and Staff 21 during the tour on 11/17/21.  They acknowledged the findings.

1. Fireplace screens have been placed in the front of fireplaces in the lobby of each cottage.

2. The Executive Director and Maintenance Director will receive additional training on the Quarterly Building Inspection - Fireplaces.

3. The Maintenance Director will take the temperature monthly and then meet with the Executive Director and review quarterly per the Quality Assurance - Maintenance Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.  

Based on 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 C240, C420, C422, C513 and C540.  

Refer to C240, C420, C422, C513, and C540.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 veteran staff (#s 5 and 13) completed the required number of hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 11/17/21 and revealed the following:

* Staff 5 (CG) and Staff 13 (MT) were hired 04/17/19 and 10/31/18, respectively. There was no documented evidence either had completed a total of 16 hours of annual in-service training related to the provision of care, including a minimum of six (6) hours related to dementia care.

The need to ensure staff completed all required training in a timely manner was discussed with Staff 1 (Executive Director) and Staff 3 (Operations Specialist) on 11/18/21. They acknowledged the findings.

1. All employee records will be reviewed to ensure 16 hours of annual in-service training with a minimum of 6 hours related to dementia care have been completed.

2. The Executive Director and Business Office Director will receive additional training on annual in-service requirements.

3. The Business Office Director will review monthly per the Quality Assurance - Business Office Review Schedule.

4. The Executive Director will ensure the corrections are completed and monitored.   

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 C252, C260, C270, C282 and C303.

Refer to C252, C260, C270, C282, and C303.