Print Inspection: T08G

The findings of the re-licensure survey conducted 03/28/22 through 03/30/22 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 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/30/22, conducted 06/22/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the second revisit to the re-licensure survey of 3/30/22, conducted on 08/16/22, 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.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who provided services to the resident for 7 of 7 sampled residents (#s 1, 2, 3, 4, 6, 7 and 8) whose service plans were reviewed. Findings include, but are not limited to:

The most recent service plans for the sampled residents were reviewed during the survey. The records lacked documented evidence that the service plans were developed by a service planning team.

On 03/30/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (Administrator), Staff 2 (Executive Director) and Staff 3 (RN). They acknowledged the findings.

Service plans:

1. All current Service Plans are being reviewed during our weekly Quality meeting (RSC, RN and Administrator) and updated with details of service planning team involved in the plans. This includes the 4 residents under review as well as any pending plans not yet complete and those coming due.

2. Every plan moving forward will be clearly documented to show they have been developed with a service planning team that includes the resident, family, legal representative, nurse, resident services coordinator and administrator. This will include all plans including move in plan, 30 day assessment, and quarterly reviews.

3.All current plans will be reviewed to ensure that proper documentation is in place by 5/29. All future plans will be evaulated and documenyed to show the full service planning team for each step move in through quarterly ongoing assessments.

4. The RSC and nurse ensure completeness and accuracy of the plans. The plans are signed off by the DHS after review.  

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure that clinical information was reviewed by the facility nurse, staff were informed of new interventions and the service plan was adjusted as necessary for 1 of 1 sampled resident (#3) who received home health services. Findings include, but are not limited to:

Resident 3's clinical record was reviewed during the survey.

* On 02/07/22 PT documented the resident continued to have back pain when in his/her recliner and recommended staff ensure s/he was scooted all the way back in the chair. In addition, PT recommended the resident's bed be lowered for safety.

* On 02/09/22 PT recommended the resident be assisted with walking daily in the hallway with a three-wheeled walker and gait belt.

* On 02/28/22 OT recommended the following treatment: "Please assist [resident] in the mornings with a hot rag (wrung out) wrapped around left wrist for arthritis, and a dry towel wrapped over that."

There was no documented evidence these recommendations were reviewed by the facility nurse, added to the resident's service plan and implemented.

* On 03/17/22 PT recommended that resident be assisted to walk to the toilet versus taking a wheelchair.

Though the facility nurse signed as having read the HH visit note, the service plan was not updated and two interviewed caregivers were not aware of the recommendation nor were they implementing it.

The need to ensure the facility nurse was reviewing outside provider visit notes, coordinating care with outside providers, and adding outside provider recommendations to resident service plans was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (LPN) and Staff 11 (Operations Specialist) on 03/30/22. They acknowledged the findings.

Coordination of Care:

1. Current residents with an outside provider are being reviewed to ensure implementation of their plan is being communicated by TSP to the care staff and monitored by the RSC.

2. Moving forward the DHS will ensure that all new 3rd party care with outside provider plans are reviewed and TSP created for caregivers to implement with the resident.

3. TSP's will be reviewed by RSC and RN weekly to determine progress and note any changes or updates for the care team.

4. Event notes will be captured on progress by nurse to determine disposition of next steps as resolved or added to permanent care plan. TSP and 3rd party follow up notes will be documented.

3. Resident 7 was admitted to the facility in 11/2021 with diagnoses including Type 2 diabetes mellitus and heart transplant. Review of the resident's MAR from 03/01/22 through 03/28/22 revealed the following inaccuracies:

* The resident was prescribed five PRN bowel medications to treat constipation. Though the MAR included an order of administration it lacked parameters as to how long to wait between administering one medication and the next if the first was ineffective.

The need to ensure MARs included resident-specific parameters and instructions for staff for the administration of multiple PRN medications was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (LPN) and Staff 11 (Operations Specialist) on 03/30/22. They acknowledged the findings.

4. Resident 8 was admitted to the facility in 11/2021 with diagnoses including Alzheimer's disease, Lewy-body dementia, irritable bowel syndrome with diarrhea and colitis. Review of the resident's MAR from 03/01/22 through 03/28/22 revealed the following inaccuracies:

* The resident was prescribed two PRN medications to treat loose stools/diarrhea. The MAR lacked written parameters for staff as to when to administer each medication.

The need to ensure MARs included resident-specific parameters and instructions for staff for the administration of multiple PRN medications was discussed with Staff 1 (Administrator), Staff 2 (ED), Staff 3 (RN), Staff 4 (LPN) and Staff 11 (Operations Specialist) on 03/30/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including spinal stenosis, chronic back pain and hypothyroidism. Review of Resident 1's MAR, dated 03/01/22 to 03/28/22 identified the following deficiencies:

The MAR lacked resident specific parameters for use of the PRN pain medications ibuprofen, oxycodone and tramadol.

In an interview on 03/29/22, Staff 3 (RN) stated the reason parameters for these medications were not included on the MAR was that Resident 1 was able to self-direct on the time and sequence of usage. However, the MAR lacked documentation of that ability.

On 03/30/22 the need to keep an accurate MAR of all medications that were ordered by a legally recognized prescriber and were administered by the facility was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 4 of 8 sampled residents (#s 1, 2, 7 and 8) whose medication records were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 03/2020.

Resident 2's MARs, reviewed from 03/01/22 - 03/28/22, revealed the following PRN bowel medications did not include resident specific parameters:

* Bisacodyl tab for constipation;

* Fleet enema for constipation; and

* MOM for constipation.

On 03/30/22, the need to ensure all medications on the MAR included resident specific parameters and instruction to staff was discussed with Staff 1 (Administrator), Staff 2 (ED) and Staff 3 (RN). They acknowledged the findings.

1. Nurse is currently reviewwing every resident who is assigned PRNs. This will ensure each resident eMAR includes personalized resident specific interventions interventions (specific music, favorite activity, snacks, redirection to different location, 1:1 time with staff, etc) and will include order and duration of interventions recommended prior to utilizing the PRN (ex:psychtropic meds.).

The nurse will monitor and assign order of PRN and duration of time between administration noted in eMAR for each PRN(ex:pain meds, bowel meds.) Notes to include individualized preference if applicable.

2.Orders to be reviewed as changes occur with updated interventions, orders, duration for each.

3. All orders reviewed during weekly Quality meeting by nurse to ensure eMAR is updated and personalized for each resident to meet their needs.

Standing topic at Med Tech bi monthly meeting to discuss PRN protocols and intervention practices.

4. DHS to review and sign off additions and changes to ensure each resident is reviewed and complete.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly-hired direct care staff (#13) completed all required pre-service dementia training. Findings included, but are not limited to:

Training records were reviewed with Staff 6 (Business Office Manager) on 3/29/22. The following deficiencies were identified:

Staff 13 (CG) was hired 02/22/22 and did not complete pre-service dementia training on the following topics:

* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;

* Strategies for addressing social needs & engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need to ensure newly-hired direct care staff completed all pre-service training prior to working independently was reviewed with Staff 6 on 03/29/22 and with Staff 1 (Administrator) on 03/30/22. They acknowledged the findings.

1. All training documents are under currently under review to ensure any missed preorientation training is immediately completed.

2. Individualized employee checklist is now in place to be completed by the staffing co-ordinator for each new hire to ensure completion of Cares (dementia) training as part of pre-orientation process before staff member works on the floor.

3. Dept. managers to review training plans of their teams to ensure compliance prior to scheduling team member on the floor.

4. Administrator to review weekly training completion reports and follow up on any staff not completing their training. This will be reviewed with the administrator and department director at weekly 1:1.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents for 1 of 1 newly-hired direct care staff (# 24) whose training records were reviewed. This is a repeat citation. Findings include, but are not limited to:

The facility's training records were reviewed on 06/22/22.

Staff 24 (CG), hired 05/13/22, lacked documented evidence the following required pre-service dementia training had been completed prior to providing direct care to residents:

* Dementia disease process including progression, memory loss, psychiatric and behavior symptoms;

* Strategies for addressing social needs and engaging in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need to ensure newly hired, direct care staff had the required pre-service dementia training with certification prior to providing care to residents was reviewed with Staff 2 (Executive Director) and Staff 25 (Staffing Coordinator). No additional information was provided.

Pre-orientation training completion:

1. All training documents are under currently under review to ensure any missed preorientation training is immediately completed.

2. Individualized employee checklist is now in place to be completed by the Staffing Co-ordinator for each new hire to ensure completion of Cares (dementia) training as part of pre-orientation process before staff member works on the floor.

3. Dept. managers to review training plans of their teams and sign off on competency checklist prior to scheduling new team member on the floor.

4. Staffing Co-ordinator to retail all training records, and monitor, schedule and track as new training is completed. Administrator will review new team member training completion as part of weekly 1:1 with Staffing co-ordinator.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled direct care staff (#21) had documentation of demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 6 (Business Office Manager) on 03/29/22 and the following deficiencies were identified:

Staff 21 (MT), hired 07/19/21, lacked documented evidence of demonstrated competency in the following required areas:

* The role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

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

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

In addition, medication technician competencies were documented and signed, but not dated.

The need to ensure staff had documentation of demonstrated competency in all required areas within 30 days of hire was reviewed with Staff 6 and Staff 1 (Administrator) on 03/29/22. They acknowledged the findings.

Training:

1. RSC to schedule any staff who is currently overdue for first 30 mandatory training to complete before working next floor shift. (ex: Med tech to complete ADL training - has been completed.) Moving forward all med techs must complete Caregiver training prior to med tech training.

2. Resident Services Coordinator to ensure all care staff including med techs have completed their nessasary care giver training in ADLs, COC's (physical, emotional and mental functioning) and are able to identify and  document resident change of condition as part of 1st 30 day training. This will be reviewed as new team members are hired, and covered in monthly meetings. This will also be reviewed during performance reviews.

3. Follow up on training weekly to review and sign off current training by RSC and will be reviewed by Administrator during weekly 1:1.

4. Training documents to be kept in Business office with completion checklist attached for review.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#24) demonstrated competency in all assigned job duties within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed 06/22/22.

There was no documented evidence Staff 24 (CG), hired 05/13/22, demonstrated competency in the following areas:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

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

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

* General food safety, serving, and sanitation.

The need to ensure documented evidence direct care staff demonstrated competency in their assigned job duties within 30 days of hire was discussed with Staff 2 (Executive Director) and Staff 25 (Staffing Coordinator) on 06/22/22. They acknowledged the findings.

Training 1st 30 completion:

1. Staffing coordinator to review completion of  1st 30 competency checklist and ensure there is a signed copy for training file.

2. Staffing Coordinator to ensure all care staff has completed1st 30 day training. This will be scheduled as new team members are hired, and and reviewed weekly. This will also be reviewed during performance check-ins to ensure training is complete and up to date.

3. Staffing Coordinator will continually review trainng completion, and will be reviewed by Administrator during weekly 1:1.

4. Training documents to be kept in Staffing coordinator office with completion checklist attached for review.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 direct care staff (#19) completed the minimum required 12 hours of annual in-service training. Findings include, but are not limited to:

Annual staff training, including monthly staff meetings and online training, were reviewed with Staff 6 (Business Office Manager) on 03/29/22.

* Staff 19 (MT) hired 01/11/18 did not have documented evidence of completing the required 12 hours of annual in-service training.

The need to ensure direct care staff completed the required annual training was reviewed with Staff 6 and Staff 1 (Administrator) on 03/29/22. They acknowledged the findings.

1. Training completion for each staff member is under review. All staff will be given current list of training that needs to be completed and department managers will follow up weekly to ensure we are in current compliance for CEU's for each.

2. At monthly All staff, breakout session CEU training will be conducted, with documentation of who was in attendance, and topic of the training with the tools utilized.  For those not in attendance each will be assigned CEU training on web based format through Silkroad. The staff member needs to complete the web training in the month of the All Staff.

3.After current training is complete, annual CEU will be monitored for each staff member by Business office. BOM will identify and post relevant training for staff to complete mandatory training.

4.These lists will be supplied at monthly

All staff meeting and updates reported to Administrator weekly on CEU training completion. This will be reviewed with directors at weekly 1:1.

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 and Life Safety records were reviewed on 03/28/22. The fire drill records did not include the following required information:

* Escape route used;

* 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 03/29/22, Staff 8 (Plant Operations Director) acknowledged the facility was not relocating or evacuating residents as part of the fire drill process.

The need to ensure fire drills were conducted according to the Oregon Fire Code, and all required information was documented, was discussed with Staff 2 (ED) on 03/30/22. She acknowledged the findings.

1.Unannounced Fire drills will be completed every other month at different times of the day, evening and night. A written fire drill record will be kept in a red binder in the training office. It will include the following:

-date and time of drill

-location of fire origin

-escape route used

-evacuation time needed

-number of residents and staff evacuated to safe zon

It will also include any problems encountered, and comments related to residents who resist or fail to participate in the drill.

2. The Plant Manager has a yearly calendar with date/time/location of the unannounced drills to be completed.

3. Any concerns or issues arising from the drills will be discussed during weekly 1:1 with Plant Ops Director and Administrator.

4.The Plant Operations manager will ensure the correct documents are placed in the red binder after each drill. The Administrator will review the binder for accuracy monthly.

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 and Life Safety records were reviewed on 03/28/22. The fire drill records did not include the following required information:

* Evidence alternate exit routes were used during fire drills to react to varying potential fire origin points.

In an interview on 03/29/22, Staff 8 (Plant Operations Director) acknowledged the facility was not relocating or evacuating residents and was not using alternate exit routes as part of the fire drill process.

The need to ensure fire drills were conducted according to the Oregon Fire Code, and all required information was documented, was discussed with Staff 2 (ED) on 03/30/22. She acknowledged the findings.

1. Fire Safety annual  training plan has been reviewed and calendared for the full year. The details were relayed to the full team with our training at April 22, 2022 all Staff meeting.

2.Staff and resident training on Fire Safety to be conducted regularly in the following manner:

Staff training including evacuation protocols and safety procedures will be included included every other month as part of all Staff training. Documentation of the training with topics covered and list of staff in attendance will be kept in a red binder in the training office. This training will include alternate evacuation routes as well as designated points of safety.

3.Drills will be performed every other month (see C420 above) and will involve live drills with residents. These ill involve alternate exit routes.Residents will be trained for these drills when resident moves in as part of their orientation, and then ongoing as part of live drills. Residents and families will also be given information during quarterly care conferences to ensure all understand our general safety procedures, evacuation methods, and designated meeting places. A written record of the fire safety training with residents including the content of the training session and residents in attendance will be kept in a red binder with the other fire manuals in the training office.

4.These trainings will be reviewed monthly by the Administrator to ensure all training is up to date.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

The building was toured on 03/29/22. Observations and interviews with Staff  8 (Plant Operations Manager) confirmed the doors by which residents could exit the facility did not have a working alarm or other acceptable system to alert staff when residents left the building.

On 03/29/22, the need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 2 (ED) and Staff 8. They acknowledged the findings and stated the doors would be equipped with a device to connect an alarm to the existing call system.

1. Exit door alarms have been installed on each of the exits doors to the property. These alarms will are now connected to the call system to alert staff to anyone exiting a door from the community.

2. open doors now sound a staff alert on devices.

3.  Administrator reviews reporting weekly.

4. RSC to follow up with Care teams to ensure all alerts are checked and cleared.

Based on observation and interview, it was determined the facility failed to ensure the exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the facility. This is a repeat citation. Findings include, but are not limited to:

Observations made on 06/22/22 revealed the alarm for the facility's exit doors did not alert staff each time a resident exited the facility. The facility did not have another acceptable system in place.  

The requirement to ensure exit doors were equipped with an operable alarming device or other acceptable system to alert staff when residents exited the facility was discussed with Staff 2 (Executive Director) and Staff 8 (Plant Operations Director) on 6/22/22. They acknowledged the findings.

Exit Door Alarms:

1. Exit door alarms have been installed on each of the exits doors to the property. These alarms will are now connected to the call system to alert staff to anyone exiting a door from the community. Door alarm times set from evening to morning in Assisted Living when the front desk is not staffed to ensure resident safety. Any doors leading in to or out of MC areas will be on alert 24/7. Staff will repond to all doors alarms to ensure resident safety and reset. No doors to be propped open causing alarms to become inactive.

2. open doors now sound a staff alert on devices and will be responded to in a timely manner.

3.  Administrator reviews reporting to identify problem areas and/or slow response times..

4. RSC to continually coach and follow up with team to ensure all alerts are checked and cleared.