Print Inspection: UXMU

The findings of the Change of Ownership survey, conducted 04/26/22 through 04/27/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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  04/27/22, conducted 08/04/22 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, and the OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 04/26/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

a. Initial delegation records for Staff 12, 13 and 14 (MTs), reviewed on 04/27/22, lacked documentation in the following area:

* That the RN took responsibility for delegating tasks and ensured supervision would occur for as long as the RN was supervising performance.

b. Staff 12's initial delegation records lacked additional documentation in the following areas:

* An RN assessment of the resident's condition; and

* How frequently the client should be reassessed by the RN, including rationale.

c.  Periodic inspection, supervision and reevaluation of delegation records were reviewed for Staff 14 (MT), and lacked documentation in the following area:

* An RN assessment of the resident's condition to determine that the diabetic condition remained stable and predictable.

The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED), Staff 2 (RN), Staff 6 (VP of Clinical Operations/RN) and Staff 7 (Director of Operations) on 04/27/22. They acknowledged the findings.

C 282 OAR 411-054-0045

- RN to perform audit of diabetic residents and ensure diabetic assessments are current and complete, new delegation assessment form to be in use by 6/26/2022.  

-RN to perform audit of insulin delegation binder to ensure delegations are current and complete monthly for six months and quarterly thereafter by 6/26/2022

-RN to complete 'OHCA- Role of the RN in community based care' to ensure knowledge of Article 47 requirements for delegation are current and complete by 6/26/2022

-RN to implement and perform diabetic/insulin management training for delegated staff by 6/26/2022, monthly to ensure compliance for three months, and as needed thereafter to enusre continuing/ongoing education.

2. Resident 2 was admitted to the facility in August 2016 with diagnoses including diabetes.

Residents 2's physician's orders and 04/01/22 through 04/26/22 MARs were reviewed.

The April 1 through 26, 2022 MARs included documentation for administration of the following medications:

* Januvia 100 mg daily for diabetes; and

* Ciclopirox 8% Solution topically to yellow/white areas of toenails daily for fungal nails.

On 04/21/22 signed physicians orders included discontinuation of the Januvia and the Ciclopirox Solution.  The facility continued to administer the medications through 04/26/22.

The need to ensure medication orders were carried out as prescribed was reviewed with Staff 1 (Executive Director), Staff 2 (RN), Staff 3 (LPN) and Staff 6 (VP of Clinical Operations) on 04/27/22. They acknowledged the findings and reported a new system for managing physicians orders was in process now.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed or had signed physician's orders for all medications being administered for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1.  Resident 1 was admitted to the facility in December 2021 with diagnoses including diabetes and CHF.

Resident 1's MARs dated 04/01/22 through 04/26/22 were reviewed.  There was no documented evidence the facility had signed physician's orders for the medications being administered to the resident.  

Interview with Staff 2 (RN) revealed the facility did not have signed physician's orders in the facility. A copy of the signed physician's orders was received on 04/27/22.

The need to ensure the facility had signed physician's orders for all medications being administered was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 04/27/22. They acknowledged the findings.

C303 411-054-0055

-

RN to perform initial audit of facility physician's orders and ensure they are complete, accurate, and current by 6/26/2022.  LN's to perform physician's order audits quarterly therafter.

-RN to implement written procedure for processing and obtaining providers signed 90 day orders and their reconcilitation by 6/26/2022

-RN to provide LN/medtech's with new policy/training regarding physician's order processing and reconciliation by 6/26/2022

-Administrator/RN to perform initial audit physician's orders to ensure MARs accurately reflect reconciled physician's orders by 6/26/2022, LN's to perform quarterly audit thereafter.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities had a thorough assessment completed by an RN, PT or OT prior to use which included, documentation of less restrictive alternatives prior to use, instruction to caregivers on the correct use and precautions of the device for 2 of 2 sampled residents (#s 1 and 2) who had half-length side rails on their beds. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in August 2016.

On 04/26/22 at 3:15 pm, Resident 2's bed was observed to have two half-length side rails in the up position.

During an interview on 04/26/22, Resident 2 stated s/he used the side rails to help with positioning and safety when in bed.  

There was no documented evidence the device with potentially restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the correct use and precautions related to the device.

The lack of side rail assessment was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 6 (VP of Clinical Operations) and Staff 7 (Director of Operations) on 04/27/22. They acknowledged the findings.

2.  Resident 1 was admitted to the facility in December of 2021.

On 04/26/22 at 3:35 pm, Resident 1's bed was observed to have two half-length side rails in the up position.

During an interview on 04/26/22, Resident 1 stated s/he used the side rails to help with positioning and to get out of the bed.  

There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT including documentation of less restrictive alternatives prior to use, nor was there evidence the service plan had identified the correct use and precautions related to the device.

The lack of side rail assessment was discussed with Staff 1 (Executive Director), Staff 2 (RN), Staff 6 (VP of Clinical Operations) and Staff 7 (Director of Operations) on 04/27/22. They acknowledged the findings.

C340 OAR 411-054-0060

-RN to perform initial audit for all restraints/devices and ensure current orders and assessments in place by 6/26/2022, RN to perform quarterly audit thereafter.

-RN to provide staff training on policy and procedure  for all restraints/devices to ensure proper assessment per policy by 6/26/2022

-RN to provide training for staff regarding safe and proper use of restraints/devices yearly and as needed for new staff and new devices with restraining qualities by 6/26/2022

-RN to implement restraint/device in EMAR "info orders" to ensure assessments are accessible and verifiable by 6/26/22.

Based on interview and record review, it was determined the facility failed to ensure fire life safety training was conducted on alternating months and documentation that fire drills included all required components. Findings include, but are not limited to:

Fire life safety training and fire drill records were reviewed on 04/27/22 and revealed the following:

There was no documented evidence the facility was providing fire life safety on alternating months.

The following components were missing from the fire drill records:

*Location of simulated fire origin;

*Escape route used;

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

*Evacuation time periods needed; and

*Number of occupants evacuated.

The need to ensure fire life safety training was conducted on alternating months and the fire drill records included all required components was discussed with Staff 1 (Executive Director) and Staff (Director of Operations) on 04/27/22. They acknowledged the findings.

C420 OAR 411-054-0090

-Maintenance Director will complete facility fire drills every other month with fire/life safety training on the alternate months by 6/26/2022

-Mainenance Director will implememnt life safety record forms to maintain fire/life safety education record by 6/26/2022

-ED, RN, and Maintenance Director to complete Oregon Care Partners fire/life safety tranining by 6/26/2022

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

On 04/26/22, the surveyor measured water temperatures in common area bathrooms on all three floors of the building. Water temperatures were above 127 degrees Fahrenheit in each common use bathroom.

The Surveyor reported the temperatures to Staff 1 (Executive Director), and she indicated the water heater would be adjusted.

That same day, water temperatures were measured at 117 degrees Fahrenheit within the required range.  

On 04/27/22, Staff 1 and the Surveyor rechecked the water temperatures and the temperatures were within the required range.

On 04/27/22, the need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 and Staff 7 (Director of Operations). They acknowledged the findings.

C645 OAR 411-054-0300

-Maintenance Director to complete audit of facility hot water outlets and adjust water temperature as needed to ensure hot water temps between 110 and 117 degress Farenheit by 6/26/2022

-Maintenance Director will perform weekly random hot water outlet temperatures to ensure hot water temps between 110 and 117 degrees Farenheit by 6/26/2022

-ED to review weekly hot water temp audits to insure compliance by 6/26/2022