Print Inspection: UGS3

The findings of the re-licensure survey, conducted 11/13/23 through 11/16/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

2. Resident 4 was admitted to the facility in 12/2020 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, chronic obstructive pulmonary disease (COPD) and colostomy.

During the acuity interview, the facility reported the resident smoked cigarettes. The resident's most recent service plan also noted the resident smoked.

The resident's most recent "Smoking Risk Evaluation" was completed 06/12/23. The facility failed to evaluate the resident's continued ability to smoke safely at least quarterly.

The need to ensure evaluations were completed quarterly was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged evaluations had not been completed quarterly.

3. Resident 7 was admitted to the facility in 09/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis and degenerative brain disease.

During the acuity interview, the facility reported the resident smoked cigarettes. The resident's most recent service plan also noted the resident smoked.

The resident's most recent "Smoking Risk Evaluation" was completed 06/12/23. The facility failed to evaluate the resident's continued ability to smoke safely at least quarterly.

The need to ensure evaluations were completed quarterly was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged evaluations had not been completed quarterly.

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation included all required elements and was updated as needed during the first 30 days and following a significant change of condition for 1 of 1 resident (#2) whose initial evaluation was reviewed, and failed to ensure evaluations were updated quarterly for 2 of 5 residents (#s 4 and 7) whose quarterly evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke). The resident's "Pre-Admission Evaluation," dated 08/21/23, was reviewed. The evaluation lacked the following required elements:

* Interests, hobbies, social, leisure activities;

* Spiritual, cultural preferences and traditions;

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

* Dressing, grooming, personal hygiene;

* Ambulation, assistive devices;

* Dental status;

* Nutrition habits, fluid preferences, and weight if indicated;

* List of treatments;

* History of dehydration or unexplained weight loss;

* Recent losses; and

* Unsuccessful prior placements.

The resident experienced several changes in service needs during the first 30 days, including a significant change of condition regarding bilateral unstageable pressure ulcers and outside provider services. There was no documented evidence the evaluation was updated with the significant change of condition or during the first 30 days.

The need to ensure the move-in evaluation included all required elements, with changes and updates made as needed during the first 30 days, was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1) Resident #2 Evaluation to be corrected/updated to reflect all missing elements and to include accurate current status of residents service needs and conditions.

Resident #4 Evaluation to be updated to include "Smoking Risk Evaluation".

Resident #7 Evaluation to be updated to include "Smoking Risk Evaluation.

2) Resident evaluations will be completed in a timely fashion with Pre-Move In Evaluation/Screening, Initial Evaluation to be completed/entered upon move in and are to include all segments with updates and modifications needed during the first 30 days, quarterly evaluation to be completed with updates reflected at 90 days and continued quarterly evaluations or with change of condition.

3) Evaluation schedule will be maintained and audited weekly.

4) It is the resposibility of the RCC to maintain the weekly evaluation schedule and update as needed. It is the responsibility of the ED to assure corrections are completed and monitored.

3. Resident 4 was admitted to the facility in 12/2020 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, chronic obstructive pulmonary disease (COPD) and colostomy.

Review of the resident's current service plan and interviews with the resident and care staff identified the following deficiencies:

a. Resident 4's most recent service plan was completed and signed on 06/11/23. The facility failed to complete service plan reviews quarterly.

b. The service plan did not include information or instructions for staff regarding the resident's use of siderails on his/her bed.

The need to ensure service plans were reviewed at least quarterly and were reflective of the resident's needs was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

4. Resident 7 was admitted to the facility in 09/2021 with diagnoses including cerebrovascular accident (stroke) with hemiparesis and degenerative brain disease.

Review of the resident's current service plan and interviews with the resident and care staff identified the following deficiencies:

a. Resident 4's most recent service plan was completed and signed on 05/08/23. The facility failed to complete service plan reviews quarterly.

b. A behavior support plan (BSP) dated 10/18/23 had not been included with the resident's service plan. There was no documented evidence the BSP had been provided to care staff for review.

The need to ensure service plans were reviewed at least quarterly and were available to staff was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

5. Resident 1 was admitted to the facility in 05/2022 with diagnoses including dementia.

Resident 1's current service plan, dated 05/31/23, and Interim Service Plans (ISPs), dated 08/15/23 through 11/01/23, were reviewed, observations of the resident were made, and interviews were conducted between 11/13/23 and 11/16/23. The following deficiencies were identified:

a. Resident 1's most recent service plan available to staff was dated 05/31/23. The facility failed to complete service plan reviews quarterly.

b. Resident 1's service plan was not reflective of the resident's needs and preferences, and did not provide clear instruction to staff in the following areas:

* Hospital bed and current sleep preferences;

* Pet;

* Hospice services, including name of provider, frequency of visits and caregiver responsibilities;

* Presence of a port on the resident's chest, including who to contact with issues;

* Current skin concerns; and

* Manager of finances.

c. Resident 1 had a significant change of condition triggered on 10/01/23 related to a significant weight gain. There was no documented evidence the service plan was reviewed and updated as needed.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, were updated quarterly and following a significant change of condition, and provided clear direction to staff was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were completed before move-in, available to staff, reviewed quarterly and following a significant change of condition, were reflective of residents' current status and care needs, provided clear instruction to staff and were implemented, for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 12/2020 with diagnoses including insomnia, hypertension, and anxiety disorder.

Interviews with care staff and Resident 3 and observations made during the survey revealed the following deficiencies:  

a. Resident 3's most recent service plan was completed 05/08/23. The facility failed to complete service plan reviews quarterly.

b. The service plan was not reflective of the resident's care needs and/or was not implemented in the following areas:

* Transfers;

* Outside provider services related to skin;

* Compression stockings; and

* Use of a CPAP (continuous positive airway pressure) machine.

The need to ensure service plans were reviewed quarterly, were reflective of the resident's current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (Interim ED) on 11/16/23. The findings were acknowledged.

2. Resident 5 was admitted to the facility in 06/2021 with diagnoses including end stage renal disease and Type 2 diabetes.

Interviews with care staff and Resident 5 and observations made during the survey revealed the following deficiencies:

a. Resident 5's most recent service plan was completed 05/01/23. The facility failed to complete service plan reviews quarterly.

b. The service plan was not reflective of the resident's care needs in the following areas:

* Dressing; and

* Hearing.

The need to ensure service plans were reviewed quarterly and were reflective of the resident's current care needs was discussed with Staff 1 (Interim ED) on 11/16/23. The findings were acknowledged.

6. Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke). During the acuity interview, Staff 1 (Interim ED) stated all resident service plans were available in binders in the staff charting room.

There was no service plan for Resident 2 in the staff charting room. During an interview at 11:30 am on 11/13/23, Staff 1 confirmed Resident 2 did not have an active service plan.

The need to ensure service plans were completed before move-in and available to staff was discussed with Staff 1 on 11/16/23. She acknowledged the findings.

1) Corrections for residents reviewed:

Resident #3 will be re-evaluated and the service plan updated to reflect specific needs for transfers, outside provider services related to skin, compression stockings and use of CPAP machine.

Resident #5 will be re-evaluated and the service plan updated to reflect needs and preferences for dressing and hearing.

Resident #4 will be re-evaluated and the service plan updated to include information and instructions for staff regarding the resident's use of siderails on his/her bed.

Resident #7 will be re-evaluated and the service plan updated to reflect instruction and interventions provided in the resident's behavior support plan, training will be provided for staff to ensure understanding of the behavior support plan.

Resident #1 will be re-evaluated and the service plan updated to reflect the resident's needs and preferences  and provide clear instruction with use of hospital bed and current sleep preferences, information regarding resident's pet, Hospice services including the name of the provider, frequency of visits and caregiver responsibilities. It will identify the presence of a port on the residents chest and direction on who to contact with issues or concerns, current skin concerns and who manages finances. Resident's weights will be evaluated and changes will be reflected in the service plan.

Resident #2 will be re-evaluated with full implementation of a service plan that is reflective of the resident's identified needs and preferences.

2) Resident Service Plans will be created and updated to reflect current actual physical and cognitive needs/utilization of assistance, including what, who, when, how often, and clear instructions as to how the service is performed and will reflect the resident's preferences. Service Plans will be created and updated by the Health Services Team including the resident and RP should they wish to participate. Service Plans will be implemented prior to move-in, updated within the first thirty days and quarterly there after or as a Change of Condition arises.

3) Areas needing correction will be audited weekly until completed.

4) It is the reaponsibility of the RCC and ED to assure the corrections are completed and monitored.

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, at least one other staff person who was familiar with or who was going to provide services to the resident and a licensed nurse if the resident needed or was receiving nursing services for 5 of 6 sampled residents (#s 1, 2, 3, 5 and 7) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3, 5 and 7's current service plans were reviewed during the survey. A group interview with six alert and oriented unsampled residents and individual interviews with sampled residents were conducted.

During the group interview on 11/14/23, multiple residents stated they had only met with their Service Planning Team or reviewed their service plan "one or two times" in the last few years of residing at the facility. During individual interviews with sampled residents, multiple residents stated they had only met with their Service Planning Team or reviewed their service plan "one or two times" in the past three years of residing at the facility.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Interim ED) on 11/16/23 at 1:45 pm. The findings were acknowledged.

1) Residents 1,2,3,5,and 7 re-evaluations will be reviewed by the multi disciplinary team, the residents and RP's who wish to participate.

2) A standing day and time will be established for the Service Planning Team to meet to review evals/re-evals. A multidisciplinary team to include the HSD, LD, RCC, ED, MT and Caregivers will review a resident's evaluation/re-evaluation and address each item with who, what, where, when, why, how and how often information and clear instructions as to the resident's needs and preferences. The Service Plan will be reviewed with residents and responsible parties who wish to participate and the care team for accuracy and clarity of updates made.

3) The ED and HSD will audit updated Service Plans weekly for the next 60 days. Ongoing monitoring will continue with twice monthly audits.

4) The ED and HSD are responsible for ensuring that corrections to the individual resident plans and to the systems are completed and monitored.

2. Resident 4 was admitted to the facility in 12/2020 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, chronic obstructive pulmonary disease (COPD) and colostomy.

The record indicated the resident experienced two changes of condition that required monitoring. The following deficiencies were identified:

a. The resident underwent eye surgery on 10/03/23. The eye clinic provided aftercare instructions for the facility.

There was no documented evidence the facility documented and communicated the aftercare instructions for staff. The facility failed to monitor and document on the resident's condition at least weekly until resolved.

b.  The resident tested positive for coronavirus disease (COVID-19) on 10/11/23. The facility developed an Interim Service Plan (ISP) which noted Resident 4's current symptoms, but lacked written instructions for staff regarding actions, interventions or monitoring. The facility documented the resident was placed on "Alert Charting" but there was no monitoring documented until 11/01/23 - three weeks after the COVID-19 exposure was identified.

The need to ensure the facility developed, documented and communicated to staff what actions or interventions were needed for a resident following a change of condition, and monitored and documented on the progress of the condition at least weekly until resolved, was reviewed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition had resident-specific instructions or interventions developed, documented and communicated to staff, and the conditions were monitored,at least weekly through resolution for 3 of 6 sampled residents (#s 1, 2 and 4) who experienced short-term changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including progressive supranuclear palsy (a neurological disorder) and dementia.

The resident's current service plan dated 05/31/23, Interim Service Plans (ISPs) dated 09/22/23 through 11/01/23, progress notes dated 08/25/23 through 11/13/23, and corresponding incident reports were reviewed. Observations of the resident and interviews with caregivers were completed between 11/13/23 and 11/16/23.

The resident had multiple documented short-term changes of condition between 08/25/23 and 11/04/23.

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

* 08/25/23 - Skin abrasion;

* 09/09/23 - Fall;

* 10/11/23 - Fall;

* 10/11/23 - Skin tear; and

* 10/25/23 - Left forearm lesion with cellulitis.

b. The following changes of condition lacked documented evidence resident-specific actions or interventions were communicated to staff on all shifts:

* 08/25/23 - Fall;

* 10/31/23 - Admission to hospice; and

* 11/04/23 - Fall.

c. The following changes of condition lacked documented evidence they were monitored, at least weekly, through resolution:

* 09/23/23 - Death of spouse.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke). The resident's current Interim Service Plans (ISPs), progress notes, and outside provider notes dated 08/22/23 through 11/13/23 were reviewed. Observations of the resident and interviews with caregivers were completed between 11/13/23 and 11/16/23.

a. Progress notes indicated the resident developed bilateral pressure ulcers on 09/10/23. There was no documented evidence the condition was monitored at least weekly.

b. Progress notes indicated the resident went to the emergency department on 09/22/23 and returned that day "possibly with a developing infection." There was no documented evidence of resident-specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution for the emergency department visit.

The need to ensure resident-specific actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored at least weekly was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1) Resident #1 re-evaluation will reflect history of falls, skin tears, abrasions lesion with cellulitis, admit to hospice and death of spouse.

Resident #4 re-evaluation will reflect history of eye procedures, history of covid positive status.

Resident #2 re-evaluation will reflect current status and instruction in regards to pressure ulcers.

2) Training will be provided for the RCC and HSD using the OAR Compliance Guidelines for COC. Addiitonal training will be provided for Med Techs and Resident Aides on appropriate identification, documentation, monitoring requirements and notifications to HSD, RCC and ED regarding resident status changes.

3) Residents undergoing a short term/significant Change of Condition will have Interim Service Plans and Alert Charting in place. Interim Service Plans and Alert Charting will be audited/monitored weekly.

4) The ED, HSD are responsible to see that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 2 sampled residents (#s 1 and 2) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including progressive supranuclear palsy (a neurological disorder) and dementia.

a. During the entrance conference on 11/13/23, staff reported Resident 1 had a significant decline in health and was admitted to hospice recently.

Review of the clinical record and interviews with staff revealed the resident was admitted to hospice on 10/30/23 due to severe protein calorie malnutrition.

Resident 1's sudden decline in health and admission to hospice constituted a significant change in condition for which an assessment by the facility RN was required. On 11/15/23 at 12:45 pm, Staff 1 (Interim ED) confirmed the facility's former RN did not complete the required RN assessment.

b. Resident 1's weight records were reviewed and revealed the following:

* 12/21/22 - 86.8 pounds;

* 04/02/23 - 94.6 pounds;

* 08/02/23 - 88.5 pounds;

* 09/01/23 - 92.6 pounds;

* 10/01/23 - 97.8 pounds; and

* 11/15/23 - 87.2 pounds (requested during survey).

From 09/01/23 to 10/01/23, Resident 1 had a weight gain of 5.2 pounds or 5.65% of his/her body weight in one month. This weight gain indicated a significant change of condition and required an RN assessment. On 11/16/23 at 1:55 pm, Staff 1 confirmed the facility's former RN did not complete the required RN assessment.

The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke). The resident's 08/22/23 through 11/13/23 progress notes, interim service plans, and outside provider notes were reviewed and interviews were conducted, and the following was identified:

A progress note dated 09/10/23 indicated the resident developed bilateral unstageable pressure ulcers on his/her heels. The pressure ulcers constituted a significant change of condition and required an assessment by the facility RN. There was no documented evidence the RN assessment was completed.

The need to ensure the facility RN conducted an assessment when a resident experienced a significant change of condition was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1) Resident #1 will be assessed by the RN and re-evaluation and Service Plan will be reflective of residents current conditions and services as well as history of weight changes and Hospice admit.

Resident #2 will be assessed by the RN and re-evaluation and Service Plan will be reflective of current conditions and services to include skin and pressure ulsers.

2) The HSD and RCC will receive training on Change of Condition using the OAR Compliance Guidelines for COC. Follow up training will be scheduled for all Med Techs and Resident Aides to identify, document, and notify HSD, RCC and ED regarding resident status changes.

3) The need for COC is considered daily as the HSD and RCC read the 24HR Communication notes and Chart Notes in QMAR every morning to idetify and respond to resident changes. The OAR Compliance Guidelines for COC will be at hand in the 24HR Communication Binder for reference. The need for Short Term and Significant Change of Condition will be evaluated daily.

4) It is the responsibility of the HSD and ED to ensure that the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules for 1 of 1 sampled resident (#5) who received insulin injections by unregulated assistive persons (UAPs). Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes a UAP 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 UAP, teaching the task, and observing the staff demonstrate the task.

Resident 5 was admitted to the facility in 06/2021 with diagnoses including IDDM (insulin dependent diabetes mellitus).

A facility acuity interview, conducted 11/13/23, revealed Resident 5 was administered insulin injections by medication technicians, who were considered UAPs. Staff 1 (Interim ED) reported there was not an RN who currently worked in the facility. Therefore, there was no RN to provide oversight and supervision of the UAPs' adherence to written instructions and performance of the task. Staff 1 further stated the facility attempted to contract with agency nurses to administer insulin to the residents and to hire a facility RN to address the concerns for the last three weeks; however, all attempts failed.

Resident 5's 11/01/23 through 11/13/23 MAR and delegation records were reviewed and revealed the following:

* Resident 5's MAR noted insulin had been given by Staff 5 (MT), Staff 6 (MT) and Staff 13 (MT) on multiple occasions;

* Delegation records provided by Staff 1 indicated delegation had been completed by the previous facility RN. That RN failed to document a recommendation that identified how the resident might continue to receive his/her ordered nursing procedure in the event the RN was no longer a member of the resident's health care team and the procedure remained ordered for the resident; and

* The UAPs were performing a nursing procedure (insulin injections) without being currently delegated to perform the task.

The survey team directed the facility to immediately stop having the undelegated MTs administer insulin to all residents and requested a written plan for ensuring insulin would be administered only by a licensed person until delegation was completed properly. A plan was submitted and approved by the survey team on 11/14/23.

On 11/16/23, the facility was able to obtain a full-time RN who began delegating MTs to administer insulin.

The need to ensure staff who administered insulin injections to residents were properly delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 on 11/14/23 and 11/16/23. The findings were acknowledged.

1) On November 22,2023 a 40 hour per week RN is retained. Immediate training, review of performing CBG's, Dexcom, insulin administration, proper documentation with administration of insulin and RN observations is completed for Resident #5. RN completed comprehensive diabetic assessment on each diabetic resident in the community.

2) RN will utilize diabetic delegation tracking tool and maintain all documentation. All Med Techs will be reviewed for re-delegation every 60 days. Newly hired med techs will receive the medication diabetic course and complete the diabetic examination with at least an 80% scoring. RN will assure teaching and observation with all diabetic delegations. New Med Techs will receive shadowing for initial 3 days and followed up by delegation of the RN.

3) RN delegations will be reviewed and monitored every 60 days and as needed.

4) It is the responsibility of the ED and HSD to ensure the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure a licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions, and the service plan was adjusted if necessary for 1 of 4 residents (#2) who received outside services. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke), and was identified during the acuity interview as receiving outside provider services. Resident 2's progress notes and outside provider notes, dated 08/22/23 through 11/13/23, were reviewed and revealed the following:

* 09/18/23 -"[E]ncourage weight shifting in recliner to avoid pressure areas. Encourage there[apeutic] ex[ercises] as outlined";

* 09/27/23 - "Encouragement [sic] daily exercise. Increase time up in [wheelchair]"; and

* 10/10/23 - "Redness under left breast - redness in peri area - barrier cream applied."

There was no documented evidence a licensed nurse was notified of the services provided, staff were informed of new interventions, or the service plan was adjusted to ensure continuity of care.

The need to ensure a licensed nurse was notified of the services provided by the outside provider to ensure that staff were informed of new interventions and the service plan was adjusted, if necessary, was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1) Resident #2 re-evaluation with service plan updated to reflect interventions and directions provided from outside health service providers with RN review.

2) RN will review all outside provider notes assuring implementation of COC and new orders. Interim service plans will be utilized for interventions and directions of services ordered by outside provider for care staff knowledge and follow through. Transfer of all information to resident's service plan will be completed.

3) Weekly evaluation of process for correction.

4) It is the responsibility of the ED and HSD to ensure the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as required in OAR 411-054-0050. Findings include, but are not limited to:

In an interview on 11/13/23 at 2:54 pm, Staff 1 (Interim ED) reported Staff 3 (Environmental Services Director) was the facility's designated Infection Control Specialist; however, Staff 3 had not completed the required training prior to the start of the re-licensure survey.

The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 on 11/16/23. She acknowledged the findings, and Staff 3 completed the required Oregon Care Partners course prior to survey's exit.

1) Facilities Environmental Services Director completed the required "Infection Control Specialist Training for Communty-Based Care" provided by Oregon Care Partners on 11/15/2023.

2) The Health Services Director will complete the required "Infection Control Specialist Training for Community Based Care" provided by Oregon Care Partners.

3.) Infection Prevention and Control process and required Certifications will be audited monthly.

4) It is the responsibility of the ED and HSD to ensure that the corrections are completed and monitored.

2. Resident 4 was admitted to the facility in 12/2020 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, chronic obstructive pulmonary disease (COPD) and colostomy.

Review of the current signed physician orders and the 10/01/23 through 11/12/23 MAR indicated the following order was not followed:

* The resident had orders for the facility to change the resident's ostomy bag/pouch system twice per week. The task was completed by the facility's medication technicians.

The MAR indicated the order was discontinued on 10/08/23. No written order to discontinue the ostomy care was found in the resident's record or provided by the facility. In an interview on 11/15/23, Staff 4, 5 and 6 (all MTs) reported they had not provided ostomy care for several weeks and did not know why the order was discontinued.

The need to ensure orders were carried out as prescribed was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 4 of 6 sampled residents (#s 1, 3, 4 and 5) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 05/2022 with diagnoses including dementia.

Resident 1's MAR, dated 11/01/23 through 11/12/23, corresponding progress notes and current physician's orders were reviewed.

The MAR was blank for the following medications or treatments:

* Acetaminophen 500 mg (for pain) on 12 occasions;

* Aripiprazole 5 mg (for depression) on four occasions;

* Atorvastatin 40 mg (for cholesterol) on four occasions;

* Bupropion 150 mg (for depression) on eight occasions;

* Double antibiotic ointment (for laceration) on 12 occasions;

* Multivitamin (supplement) on five occasions;

* Sulfa/Trim (for cellulitis) on nine occasions;

* Tums (supplement) on five occasions; and

* Vitamin D3 (supplement) on five occasions.

On 11/14/23 at 12:35 pm, the surveyor and Staff 6 (CG/MT) reviewed the MAR and medication supply. Staff 6 was unable to verify if the above orders had been followed.

The need to ensure physician orders are carried out as prescribed was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

3. Resident 3 was admitted to the facility in 12/2020 with diagnoses including hypertension.

The resident's 11/01/23 through 11/13/23 MAR and physician's orders were reviewed and revealed the following:  

Resident 3 had physician orders for compression hose to be put on daily at 8:00 am and taken off daily at 8:00 pm. In an interview with Resident 3 on 11/15/23 at 9:30 am it was stated the compression hose had not been applied "since before I moved to this apartment," which was in 07/2023. Resident 3 was observed to not have the compression hose on throughout the survey process.

The need to ensure the facility followed physician orders was discussed with Staff 1 (Interim ED) on 11/16/23 at 1:45 pm. The findings were acknowledged.

4. Resident 5 was admitted to the facility in 06/2021 with diagnoses including end stage renal disease and type 2 diabetes.

The resident's 11/01/23 through 11/13/23 MAR and physician's orders were reviewed and revealed the following:

a. Resident 5 had physician orders for CBG level to be checked daily before meals and at bedtime. The physician's order directed the facility to notify the MD if the CBG level was greater than 400. Review of the MAR indicated there were nine occasions where Resident 5's CBG level was greater than 400.

In an interview on 11/14/23, Staff 2 (RCC) confirmed the facility did not have documented evidence the provider had been notified when the resident's CBG level was greater than 400.

b. The 11/01/2023 through 11/13/2023 MAR was reviewed and revealed a blank on 11/07/23 for administration of Humulin N 100-U/ML Pen 3ML to inject 13 units subcutaneously every morning for diabetes. In an interview with Staff 1 (Interim ED) on 11/14/2023 at 9:30 am, it could not be confirmed if the morning insulin dose had been administered on 11/07/23.

The need to ensure the facility followed physician's orders was discussed with Staff 1 on 11/16/23. The findings were acknowledged.

1) Resident #1 MAR reviewed by RN and Hospice RN, orders clarified and updated for accuracy.

Resident #4 MAR reviewed, faxed PCP for clarification and accuracy of order for ostomy care and implemented on resident MAR, Med Tech training provided for colostomy care (taught task).

Resident #3 MAR reviewed by RN, compression stockings are purchased and order clarified. Teaching provided for care staff and med techs on use of compression stockings and instruction identified on ISP for daily placement and removal at night. Staff are to document and notify PCP and RN of all refusals.

Resident #5 MAR reviewed by RN. Med Techs trained on medication administration, required notifications to MD and RN. Residents orders for notification of CBG levels greater than 400 followed with notifications and documentation in notes when sent to MD and RN notified. RN implementation with 40 hours per week and current delegations in place to negate failure of administration of insulin.

2) All Med Techs will complete Oregon Care Partners Medication Adinistration Training for Unlicensed Medication Technicians. Ongoing training will be provided weekly for 2 months. Monthly ongoing after completion for sustainabliity.

3) Area to be reviewed/evaluated weekly.

4) It is the responsibility of the ED and HSD to ensure that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified if a resident refused consent to an order for 3 of 5 sampled residents (#s 1, 2 and 4) who had documented medication refusals. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 12/2020 with diagnoses including cerebrovascular accident (stroke) with hemiparesis, chronic obstructive pulmonary disease (COPD) and colostomy.

Resident 4 had orders for the facility to administer Refresh P.M. ointment to both eyes nightly. Review of the MAR between 11/01/23 and 11/12/23 indicated the resident refused consent to the order on 10 of 12 days.

There was no documented evidence the facility notified the physician or other practitioner of the refusals. In an interview on 11/15/23, Staff 2 (RCC) acknowledged the facility lacked a system for notifying prescriber when a resident refused an order.

The need to ensure the physician or other practitioner was notified if a resident refused consent to an order was reviewed with with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2022 with diagnoses including dementia.

The resident's MAR, dated 11/01/23 through 11/12/23, was reviewed and revealed facility staff documented Resident 1 refused the following orders:

* Acetaminophen (a pain reliever) two times;

* Atorvastatin (for cholesterol) two times;

* Bupropion (for depression) two times;

* Buspirone (for anxiety) one time;

* Calcium antacid (supplement) one time;

* Docusate sodium (for constipation) three times;

* Donepezil (for dementia) two times;

* Latanoprost (for glaucoma) one time;

* Memantine (for dementia) one time;

* Multivitamin (supplement) one time;

* Rhopressa (for dry eyes) one time; and

* Vitamin D3 (supplement) one time.

On 11/15/23 at 12:45 pm, Staff 1 (Interim ED) confirmed there was no documented evidence the facility notified Resident 1's physician of the refusals.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 on 11/16/23. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 08/2023 with diagnoses including cerebrovascular accident (stroke). The resident's MAR, dated 11/01/23 through 11/12/23. was reviewed and revealed facility staff documented s/he refused the following orders:

* Acetaminophen (a pain reliever) 21 times;

* Ipratropium albuterol (for chronic obstructive pulmonary disease) nine times;

* Gabapentin (for pain) one time; and

* Polyethylene glycol (for constipation) five times.

There was no documented evidence the prescriber was notified of the refusals.

The need to notify the physician or other practitioner when a resident refused consent to an order was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1)Med Tech Training provided on 11/15/23 included review of Policy and Procedure for Missed/Refused Medications including the requirement for Physician Notification of all instances.

Resident #4 refused medications on 10 occasions pertaining to Refresh P.M. Ointment will be notified to the MD.

Addendum:Resident #1 refused medications identified for period 11/1/23 - 11/12/23 will be notified to the MD.

Resident #2 refused medications identified for period 11/1/23 - 11/12/23 will be notified to the MD.  

2) Med Techs will receive ongoing training, pre-formatted Missed/Refused Medication Physician Fax form is implemented and instructions provided in training. Daily audit of missed/refused medications/treatments with review of fax binder to ensure physicians notifications will be completed.

3) Missed/Refused medications and treatments with PCP notifications will be reviewed/audited daily.

4) It is the responsibility of the ED and RCC to ensure the corrections are completed/monitored.

Based on interview and record review, it was determined the facility failed to ensure PRN medications that were given to treat a resident's behavior had resident-specific parameters and non-pharmacological interventions were attempted. and documented to be ineffective, prior to their administration for 1 of 2 sampled residents (#1) who were prescribed psychotropic medications. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 05/2022 with diagnoses including anxiety.

Review of Resident 1's MAR, dated 11/01/23 through 11/12/23, and physician orders revealed the following:

* Resident 1 was prescribed lorazepam 0.5 mg - take one tablet by mouth every two hours as needed for anxiety, restlessness or shortness of breath; and

* Lorazepam was documented as administered to the resident on five occasions between 11/03/23 and 11/12/23.

The facility lacked documented evidence of resident-specific parameters regarding when unlicensed staff were to administer lorazepam, non-pharmacological interventions were attempted and were ineffective prior to administration of the lorazepam, and information on which non-pharmacological interventions to attempt.

In an interview on 11/14/23, Staff 6 (CG/MT) confirmed the electronic MAR did not have resident-specific parameters or non-pharmacological interventions listed for staff to attempt prior to administering the PRN medication.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        The need to ensure medications that treat a resident's behaviors had resident-specific parameters and non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (Interim ED) on 11/16/23. She acknowledged the findings.

1) Resident #1 MAR reviewed with update to PRN psychtropic medications adding resident specific parameters regarding when unlicensed staff are to administer the medication and non pharmacological interventions to attempt. MAR will be adjusted to cue med tech for interventions and med tech to document interventions attempted and effectiveness.

2) MAR's will be reviewed by the HSD monthly and by pharmacy RN quarterly. Addendum: New physicians medication orders will be reviewed with triple check system by the Med Tech, RCC and RN daily to assure accuracy of order. All new PRN Psychotropic medications will be reviewed and a minimum of three resident-specific interventions for use prior to administration will be entered in the MAR with required documentation of interventions attempted and effective/non-effective status.

3) System will be audited/evaluated weekly.

4) It is the responsibility of the ED and HSD to ensure correction is completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the acuity-based staffing tool (ABST) was updated no less than quarterly or with a significant change of condition for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 7) whose ABST data was reviewed. Findings include, but are not limited to:

The facility's ABST was reviewed with Staff 1 (Interim ED) on 11/16/23. Four of four sampled residents' ABST data (#s 3, 4, 5, and 7) did not show evidence of being updated at least quarterly. Two of two sampled residents' ABST data (#s 1 and 2) did not show evidence of being updated when they experienced a significant change of condition.

The need to ensure ABST records were updated no less than quarterly and/or with a significant change of condition was discussed with Staff 1 on 11/16/23. She acknowledged the findings.

1) Residents 1,2,3,4,5 and 7 to be re-evaluated with updates to service plans with multi disciplinary team meetings to include resident and RP. RN to assess residents 1 and 2 for coc.

2) Service Plan schedule to be maintained and updated weekly with quarterly and change of conditions completed timely. State provided ABST tool completed with updates maintained. Ongoing usage of agency to meet staffing needs with hiring of new staff ongoing.

3) Weekly auditing and evaluation until completion with monthly audits there after.

4) It is the responsibility of the ED, RCC and HSD to ensure corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within the first 30 days of hire for 4 of 4 sampled direct care staff (#s 11, 14, 17 and 18). Findings include, but are not limited to:

Facility training records were reviewed with Staff 20 (Business Office Manager) on 11/14/23. The following was noted:

a. Staff 11 (CG), hired 08/15/23, and Staff 14 (MT), hired 04/20/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation.

b. Staff 17 (CG), hired 08/11/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Changes associated with normal aging; and

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

c. Staff 18 (MT), hired 06/20/23, lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation; and

* The ability to perform safe medication and treatment administration unsupervised.

The surveyor requested Staff 18 to be removed from the schedule as an MT until she had documentation of demonstrated satisfactory performance in all assigned job duties.

The need to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within the first 30 days of hire was discussed with Staff 1 (Interim ED) and Staff 20 on 11/14/23. The findings were acknowledged.

1) Staff #11, #14, #17 and #18 to receive shadowing and added training with completion of documented competencies and satisfactory perfomance in all areas to include areas identified. Staff #18 removed from schedule and RCC was able to locate training documentation dated 4/20/23 with completion date of 5/6/2023.

2) A new hire checklist will be implemented that includes pre-service training and additional trainings that are required to be completed in the initial 30 days of employment. A job specific competency checklist will be maintained by the RCC until completed. The job specific skills checklist will identify competencies that must be completed pre-service and those that must be completed within 30 days. The job specific skills check list will include the dates of observation and skills check and will be signed by the trainer and trainee. The RCC will not schedule the mew employee until the pre-service skills checklist is completed. The RCC will not schedule the new employee beyond 30 days unless the required items identified on the job specific skills checklist have been completed. When the pre-service items and the items required within 30 days have been completed, the documentation will be given to the BOM for placement in the employees record.

3) Staff trainings and documentation will be evaluated monthly.

4) It is the responsibility of the RCC, BOM and ED to ensure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 4 of 4 sampled long-term staff (#s 13, 15, 16 and 19) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 20 (Business Office Manager) on 11/14/23. The following was identified:

Staff 13 (MT/CG), hired on 08/29/19, Staff 15 (MT), hired on 07/12/18, Staff 16 (MT), hired 02/27/17, and Staff 19 (CG), hired 01/15/09, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, of which at least six hours were related to dementia care.

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training, was discussed with Staff 1 (Interim ED) and Staff 20 on 11/14/23. The findings were acknowledged. No further information was provided.

1) Annual in-service schedule to include monthly trainings on topics of provisions of care for persons in community based care settings, chronic diseases, dementia care and infection control and prevention implemented by interim ED.

2) All employees are required to attend monthly in services and employment is contingent upon attendance. The ED will maintain annual schedule assuring required topics for continued education to include disease outbreaks and infection control, provisions of care for persons in cbc setting, chronic diseases and dementia training.

3) Monthly in-service training and attendance will be evaluated monthly.

4) It is the responsibility of the ED to ensure that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to include all required components on fire drill records and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records dated 08/2023 through 10/2023 were reviewed and revealed the following:

1. Unannounced fire drills were not consistently conducted every other month and the fire drill records lacked the following components:

* Location of simulated fire;

* Escape route used; and

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

2. There was no documented evidence alternate routes were used during the fire drills.

3. Fire and life safety instruction was not consistently provided to staff on alternate months.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Interim ED) on 11/14/23. The findings were acknowledged. No further information was provided.

1) Annual calendar implemented with alternating months for Fire and Life Safety training and Unannounced Fire Drills.

2) Education provided to the ESD utilizing OAR 411-054-0090 to ensure understanding of requirements. Review of Fire Drill Records to ensure further understanding of documentation requirements. Annual schedule is implemented outlining specific trainings for staff and Fire Drills alternating months.

3) Fire Life and Safety requirements will be evaluated monthly.

4) It is the responsibility of the ESD and ED to ensure that the correctios are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were reinstructed at least annually. Findings include, but are not limited to:

Fire and life safety records were requested and reviewed during the survey. The following was lacking from the records:

* Documentation of fire and life safety training provided to residents within 24 hours of move-in; and

* Documentation of annual fire and life safety training provided to residents.

During the group interview on 11/14/23, six alert and oriented unsampled residents confirmed they had not received fire and life safety training upon move-in and were not reinstructed at least annually.

The need to ensure residents received fire and life safety training within 24 hours of admission and were reinstructed at least annually was reviewed with Staff 1 (Interim ED) on 11/14/23. The findings were acknowledged. No further information was provided.

1) Resident Fire and Life Safety Training scheduled for 12/15/2023, invitations sent to RP's for group training and discussion. One on one Fire and Life Safety training in process at this time with full documented Emergency/Disaster Orientation.

2) All residents at the time of move in will receive Fire and Life Safety Training by the facility ESD with documented Emergency/Disaster Orientation. All resident's will receive re-training annually on their Anniversary date with continued renewal each year of documented teaching.

3) Resident Fire Life and Safety Training will be evaluated monthly.

4) It is the responsibility of the ESD and ED to ensure this is completed and monitored.