Print Inspection: WL0C

The findings of the re-licensure survey, conducted 04/01/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCCMemory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 04/04/24, conducted 08/07/24 through 08/08/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation addressed all required elements for 1 of 1 sampled resident (#4) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 03/2024 with diagnoses including dementia. The resident's move-in evaluation dated 03/06/24 was reviewed and lacked the following elements:  

* Customary eating routine;

* Personality;

* How the resident expressed pain or discomfort; and

* Environmental factors that impacted the resident's behavior.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Resident #4 Service plan updated to reflect additional information that was not included in the move in evaluation.

Move in evaluations will continue to be done in a collaborative manner between adminstrator, resident and resident representatives.  Efforts will be made to gather as much information as possible prior to move in date.  Any information that is unknow will be documented as "TBD at a later date with resident/rep and/or NA.  

Move in evaluations will be reviewed by RN, administrator and/or designee for thoroughness prior to each resident move in date.

Audits will be completed by Admin weekly X 4 weeks and then monthly X 90 days for ongoing compliance  

2. Resident 3 was admitted to the MCC in 09/2023 with diagnoses including chronic obstructive pulmonary disease and dementia.

The current service plan dated 03/11/24 and progress notes from 01/01/24 through 03/31/24 were reviewed. Observations and interviews with staff and Resident 3 were completed during the survey. The following was identified:

The service plan lacked information and instructions for providing care in the following areas:

* Recent behaviors and interventions;

* Refusals of care;

* Use of portable oxygen concentrator; and

* Emergency evacuation assistance.

The need to ensure the service plan was reflective of Resident 3's care needs and included clear directions to staff regarding the delivery of services was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and preferences, and provided clear direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2, and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2022 with diagnoses including Parkinson's disease and dementia.

Resident 1's current service plan, dated 03/18/24, was reviewed, observations were made, and interviews were conducted between 04/01/24 and 04/04/24. Resident 1's service plan was not reflective of the residents' needs and preferences and did not provide clear instruction to staff in the following areas:

* Use of fingerless gloves;

* Transfers;

* Mobility;

* Use of four wheeled walker;

* Signs, symptoms, and communication relating to bowel movement needs;

* Evacuation ability and assistance needed;

* Easy to chew foods;

* Assistive devices used and assistance for meals;

* Toileting assistance, transfers, dressing, and hygiene; and

* How resident communicated or expressed pain.

The need to ensure service plans were reflective of residents' needs and preferences and provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Parkinson's disease and dementia.

The resident's current service plan dated 03/08/24 was reviewed, interviews were conducted, and observations were made. The service plan was not reflective of resident's needs and preferences and did not provide clear directions to staff in the following areas:

* Evacuation assistance; and

* Behaviors and interventions.

The need to ensure service plans were reflective and provided clear direction regarding the delivery of services was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Resident 2 and 3 services plans have been updated as of   to reflect specific needs and preferences.  Resident 1 has discharged.

RN and Admin to discuss any service plan changes during daily morning stand up meetings to ensure all new information is included in current service plan.

Administrator and/or designee will review all current service plans for accuracy, updates as indicated. .

Administrator and/or designee will audit weekly X 4 weeks and then monthly X 90 days to ensure ongoing compliance, then ongoing evaluation of service plans during quarterly meetings.  

Based on observation, interview, and record review, it was determined the facility failed to ensure resident-specific actions or interventions were determined, documented, and communicated to staff on each shift, made part of the resident record, and changes of condition were monitored to resolution for 3 of 3 sampled residents (#s 1, 2, and 3) who experienced short-term changes condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the MCC in 09/2023 with diagnoses including chronic obstructive pulmonary disease and dementia.

Review of the resident's current service plan and progress notes between 01/01/24 to 03/31/24 and interviews with staff indicated the resident experienced multiple changes of condition, including the following:

* 02/20/24 - Fall resulting in injuries to right elbow and back;

* 03/09/24 - Injury to left ring finger;

* 03/17/24 - The resident was found on the floor, reporting s/he had fallen while transferring from the bed to the wheelchair and had hit his/her head on the wall;

* 03/28/24 - Increased behaviors; and

* 03/29/24 - Refusals of care.

Though the facility placed the resident on "Alert Charting" following each incident, there was no documented evidence the facility consistently determined actions or interventions specific to each change of condition, communicated the determined actions or interventions to staff on each shift, and monitored the changes through resolution.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

2. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and anxiety.

Observations of the resident and interviews with staff were completed. The resident's service plan, dated 03/18/24, and progress notes, dated 01/01/24 through 04/01/24, were reviewed. The following was revealed:

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

* 01/18/24 - Diet change from regular textures to easy chew.

b. The following short-term changes of condition lacked communication of resident-specific determined actions or interventions to staff on all shifts:

* 01/01/24 - Increase in quetiapine for mood;

* 01/11/24 - Fall;

* 02/02/24 - New bowel medication for constipation; and

* 02/15/24 - Constipation and change to bowel meds.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Parkinson's disease and dementia.

Observations of the resident and interviews with staff were completed. The resident's service plan, dated 03/08/24, and progress notes, dated 01/01/24 through 04/01/24, were reviewed. The following was identified:

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

* 02/06/24 - Edema in lower extremities; and

* 02/19/24 - Two skin tears on back and bruise on right hip.

b. The following short-term changes of condition lacked communication of resident-specific determined actions or interventions to staff on all shifts:

* 02/18/24 - New onset agitation;

* 02/23/24 - New medication (trazadone) for sleep;

* 03/13/24 - Increase in quetiapine for agitation;

* 03/13/24 - Decrease in duloxetine (an antidepressant) dosage;

* 03/13/24 - Decrease in carbidopa-levodopa (for Parkinson's disease) dosage;

* 03/15/24 - Urinary tract infection; and

* 03/16/24 - New medication (nitrofurantoin) for urinary tract infection.

The need to ensure actions or interventions for short-term changes of condition were documented and communicated to staff on each shift and the changes of condition were monitored weekly through resolution was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Resident 2 and 3 short term change of condition has stabalized, areas in Service plan needing updated have been completed.

RN to educate medication tech and care givers on policy and procedure for alert charting, to ensure communication and documenation is in place for each shift through resolution that is clear and specific to resident needs.

RN and/or designee to place residents on alert for any short term change of condition.  Temporary Serivce plan changes will be posted on communication board, as well as in the chart,  to ensure all staff are aware of interventions and monitoring.

All short term changes of condition will be discussed during daily stand up meetings.  Audit of short term change of conditions will be completed by RN weekly X 4, then monthly X 90 days.

RN, Adminstrator and/or designee will ensure service plans are up to date with all short term changes in condition.    

Based on observation and interview, it was determined the facility failed to establish and maintain effective infection prevention and control protocols. Findings include, but are not limited to:

Observations completed 04/01/24 through 04/04/24 noted the following:

a. During lunch service, in both dining room areas, observations revealed multiple staff who did not complete one or more of the following:

* Proper hand hygiene prior to and/or in-between assisting residents with dining;

* The use of a protective barrier between assisting with meals and ADL care; and

* Proper covering of ready to eat food and beverage prior to transportation and service.

b. Staff 3 (CG) and Staff 12 (CG) were observed providing toileting care for Resident 1 at 10:25 am on 04/02/23. Staff 3 and Staff 12 donned gloves in the dining room without performing hand hygiene. Both staff assisted Resident 1 out of a recliner and transferred the resident into his/her wheelchair. Staff 12 wheeled the resident to his/her bathroom. In the bathroom, both staff proceeded to assist the resident with transferring to the toilet. Staff 3 assisted resident with pulling down his/her pants and brief, removed and discarded soiled brief, and performed toileting hygiene. Without removing soiled gloves, Staff 3 continued assisting with care, changing the resident's brief, and dressing. Staff 3 answered a call on her walkie talkie, then removed her soiled gloves, donned clean gloves, and went to assist with another resident without performing hand hygiene.

c. Throughout the survey, observations were made of sampled and unsampled residents using the same communal blankets provided by the facility, located on each recliner in a common area. On 04/04/24, Staff 1 (RN) stated the facility did not have a system in place to ensure blankets were laundered and/or disinfected between each use.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Staff #3 and #12 have been inserviced on proper hand hygeine, don/doff of gloves and thorough infection control.

100% of staff will be inserviced on infection control, proper hand hygiene and proper food handling /use of protective barrier when assisting/preparing meals on or before 5/25/24.  Addressed proper don/doff of gloves and routine laundering of blankets after resident use, inlcuding during toileting /ADL care.   

100% audit of staff participation in infection control and hand hygiene training to ensure that all staff received education.

Staff will be audited by administrator or RN weekly for 4 weeks, at varying meals, care activities and shifts, to ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the MCC in 09/2022 with diagnoses including dementia and had a recent history of frequent constipation.

Resident 1's current physician's orders, the MAR dated 03/01/24 through 04/01/24, and bowel monitoring records dated 03/04/24 through 03/31/24 were reviewed.

The resident had a signed physician order to receive 17 grams of polyethylene glycol powder by mouth every day as needed for constipation. Within the order, staff were instructed to administer the polyethylene glycol if the resident did not have a bowel movement in 48 hours.

No bowel movement was documented in the resident's chart and polyethylene glycol was not documented as administered in the MAR on the following occasions:

* 03/07/24 through 03/09/24;

* 03/11/24 through 03/12/24;

* 03/14/24 through 03/17/24;

* 03/22/24 through 03/24/24; and

* 03/26/24 through 03/28/24.

On 04/04/24, Staff 1 (RN) confirmed the facility failed to administer the prescribed as needed dosing of polyethylene glycol when the resident did not have a bowel movement in 48 hours.

The need to ensure all medications were carried out as prescribed was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2024 with diagnoses including Parkinson's disease and dementia.

The resident's 03/01/24 to 04/01/24 MAR and physician orders dated 02/06/24 and 03/22/24 were reviewed. The following was identified:

The resident had orders for:

* Acetaminophen, 1000 mg (for moderate pain), administer two tablets three times daily, or 3000 mg per day; and

* Acetaminophen, 325 mg (for pain), administer two tablets every four hours as needed, not to exceed 3000 mg of APAP (acetaminophen) from all sources in 24 hours.

The facility administered the PRN acetaminophen to the resident on 03/07/24 and 03/20/24, thus exceeding the maximum of 3000 mg in 24 hours.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Resident 1 discharged from facility.   

Resident #2 medication parameters adjusted to reflect appropriate doses of medication.  PRN Tylenol discontinued per physician orders.  

RN inservice with all Med Techs to discuss proper administration of PRN medication parameters and bowel monitoring

RN to review charts weekly for 4 weeks, monthly therafter to ensure adequate and appropriate administration of medication per parameters.  RN to monitor ongoing

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to an order for 1 of 1 sampled resident (#2) who refused medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 04/2024 with diagnoses including Parkinson' disease, dementia, depression, hypertension, and insomnia. The resident's 02/01/24 to 04/01/24 MARs were reviewed and revealed facility staff documented Resident 2 refused the following orders:

* Atorvastatin (for hyperlipidemia), on one occasion;

* Duloxetine (for depression), on one occasion;

* Melatonin (a sleep aid), on one occasion;

* Vitamin B-12 (a supplement), on three occasions;

* Vitamin D3 (a supplement), on three occasions;

* Acetaminophen (for pain), on six occasions;

* Senna (for constipation), on eight occasions;

* Carbamide (for ear pain), on one occasion;

* Polyethylene glycol (for constipation), on two occasions;

* Carbidopa-levodopa 100 mg tablet (for Parkinson's disease), on two occasions;

* Carbidopa-levodopa 200 mg tablet (for Parkinson's disease), on four occasions; and

* Quetiapine (for dementia), on one occasion.

In an interview on 04/04/24 at 10:55 am, Staff 1 (RN) confirmed there was no documented evidence the facility notified Resident 2's physician of the refusals.

The need to ensure the physician or other practitioner was notified when a resident refused to consent to an order was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Resident 2 physician has been notified of resident recent refusals of medications.

RN has audited MAR for last 30 days to ensure if other resident refusals exist, provider(s) have been notified.

RN to provide Med Tech inservicing regarding medication refusals and notification of provider.  

RN, administrator and/or designee to review medication refusals at daily stand up meeting.  RN to communicate with hospice and providers to get a written order of when they would like to be notified of medication refusals.

RN to monitor ongoing  

Based on interview and record review, it was determined the facility failed to ensure resident-specific parameters and instructions for PRN medications were included on the MAR for 1 of 3 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility with diagnoses including Parkinson's disease and dementia. The resident's 03/01/24 to 04/01/24 MAR was reviewed and revealed the following:

The following administered PRN medications lacked resident-specific parameters or instructions to staff:

* Acetaminophen (for pain); and

* Morphine sulfate (for pain).

During an interview at 10:22 am on 04/04/24, Staff 1 (RN) confirmed the PRN medications lacked resident-specific instructions or parameters for unlicensed staff.

The need to ensure PRN medications included resident-specific parameters and instructions to unlicensed staff was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Resident 2 order use and need has been reviewed with physician, updates for resident specific parameters made to record as indicated.   

100% audit has been completed to ensure parameters are resident specific, records updated as indicated.

All Med Techs will be inserviced on or before 5/25/24 regarding specific order parameters are in place for PRN order.

RN will review PRN use weekly X 4 weeks and then monthly X 90 days to ensure parameters for use are in place for use.

RN to monitor ongoing.   

Based on interview and record review, it was determined the facility failed to ensure staff attempted non-pharmacological interventions and documented they were ineffective prior to administering PRN psychotropics for 2 of 3 sampled residents (#s 2 and 3) who were prescribed PRN psychotropics. Findings include, but are not limited to:

1. Resident 3 was admitted to the MCC in 09/2023 with diagnoses including chronic obstructive pulmonary disease, dementia, and anxiety disorder.

The resident's 03/01/24 through 03/31/24 MAR and signed physician orders were reviewed.

The resident was prescribed lorazepam PRN, administer 0.5 mg every four hours as needed for anxiety and restlessness.

Resident 3 was administered lorazepam on 03/07/24 and 03/20/24. There was no documented evidence non-pharmacological interventions were attempted with ineffective results prior to administration.

In an interview on 04/04/24, Staff 1 (RN) confirmed there was a lack of documentation that non-pharmacological interventions were attempted and ineffective prior to the medication administration on 03/07/24 and 03/20/24.

The need to document that non-pharmacological interventions were attempted without success prior to administering a PRN psychotropic medication was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

2. Resident 2 was admitted to the facility in 04/2024 with diagnoses including Parkinson's disease, dementia, depression, and insomnia.

Review of the resident's 02/01/24 to 04/01/24 MAR and current physician orders revealed the following:

Resident 2 was prescribed lorazepam PRN for anxiety or agitation. The facility lacked documented evidence non-pharmacological interventions were tried and ineffective prior to administration of the medication on 13 occasions between 02/17/24 and 03/17/24.

During an interview at 10:22 am on 04/04/24, Staff 1 (RN) confirmed the lack of documentation that non-pharmacological interventions were attempted and ineffective prior to the medication administration.

The need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Resident 2 and 3:  order and MAR updated to reflect appropirate interventions and parameters for PRN psychotropic medication use.  

100% audit has been completed to ensure non-pharmalogical interventions are identfied in resident chart.  Interventions and documentation parameters, updated as indicated.

All Med Techs and CareGivers will be inserviced on or before 5/25/24 regarding specific order parameters for PRN psychoactive  administration, timing and specific indication defined in the order, behavior chart all interventions and the effectiveness of interventions prior to administering PRN psychoactive medications.

RN will review charting weekly for 4 weeks and   quarterly there after to assure all direct staff are charting appropriately.

RN to monitor ongoing

2.  Resident 3 was admitted to the MCC in 09/2023 with diagnoses including chronic obstructive pulmonary disease and dementia.

Resident 3 was identified during the entrance conference on 04/01/24 to have side rails on his/her bed.

During an interview with the resident on 04/02/24, the surveyor observed one half-length side rail on the resident's hospital bed in the up position.

A review of the resident's current service plan, dated 03/11/24, indicated the resident had side rails on both sides of the bed; however, there was no documented evidence caregivers had been instructed on the correct use and precautions related to side rails.

On 04/02/24, Staff 1 (RN) confirmed she had not instructed staff on the correct use and precautions for using side rails.

Requirements regarding the use of devices with potentially restraining qualities was discussed with Staff 1 (RN) on 04/02/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure instruction was provided to caregivers on the correct use of supportive devices with potentially restraining qualities and precautions related to the use of the device, and documentation of the use of the device was in the resident's service plan for 2 of 2 sampled residents (#s 1 and 3) who had a supportive device with potentially restraining qualities. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 09/2022 with diagnoses including Parkinson's disease and dementia.  

Observations of the resident's bed during the survey from 04/01/24 through 04/04/24 revealed half-length, bilateral side rails on the bed. The left bilateral side rail was observed on the bed in the down position and the right bilateral side rail was observed up and secure.

There was no documented evidence instruction was provided to staff on the correct use and precautions of use of the device.

On 04/02/24 at approximately 10:35 am, staff interviewed stated the following regarding instruction provided on the correct use of the supportive device with potentially restraining qualities and precautions related to the use of the device:

* Staff 12 (CG) stated she could not recall if she was trained on how to use side rails; and

* Staff 3 (CG) stated she was shown how to use side rails by another caregiver and was not taught the precautions and risks related to using side rails.

On 04/02/24 at 2:00 pm, Staff 1 (RN) confirmed the lack of documented staff training associated with correct use of the supportive device with potentially restraining qualities and that staff had not been trained on the precautions and risks related to the use of the device.

The need to ensure instruction was provided to caregivers on the correct use of supportive device(s) with potentially restraining qualities was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Resident 1 and 3: service plan updated to reflect instructions for proper bed rail use.

100% of staff to be instructed on proper use of bed rails on or before 5/25/24.

RN to review use and need for retrictive device quarterly.  New staff will be inserviced on use of restrictive devices upon hire.  100% of charts will be adutied for use of restricted devices/bed rails to ensure proper instructions are included in each service plan.  

RN or designee will ensure all staff have been instructed on proper use of bed rails and service plans are up to date with instructions of use.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted with all required elements documented and failed to provide fire and life safety training to staff on alternate months per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records, reviewed between 10/2023 and 03/2024, revealed the following:

a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

* The escape route used;

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

* Evacuation time-period needed;

* The number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

b. Staff interviewed did not know the designated point of safety.

c. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills.

The need to ensure fire drills and fire and life safety training was provided and documented as required was reviewed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Fire Drill that includes relocation/partial evacuation of residents to safe area has been completed.

Maintenance staff to be inserviced by adminstrator on or before on conduction fire drills including the documentation requirements and the movement of residents.

Safety meetings will include fire and life safety, at a minimum of every other month.    

Administrator or designee to audit fire drill and safety meeting documentation monthly for 3 months.   

Admin to monitor ongoing

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

The facility's fire and life safety records were reviewed on 04/02/24.

Although the facility documented some training to residents upon 24 hours of admission to the facility, the instruction did not include general safety procedures, evacuation methods, responsibilities during fire drills, and the designated meeting place outside the building or within the fire safe area in the event of an actual fire.

On 04/02/24 at 2:27 pm, Staff 2 (Maintenance Director) stated he was unaware residents were required to be re-instructed at least annually in fire and life safety procedure training.

On 04/04/24 at 12:45 pm, Staff 1 (RN) stated she did not know residents needed to be re-instructed at least annually in fire and life safety procedure training.

The need to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 on 04/04/24. She acknowledged the findings, and no additional documentation was provided.

Current residents do not have the mental capability to allow for annual instruction of fire safety, Service plan has been updated to reflect this, in accourdance to OAR. Service Plan to reflect if resident is capable of retention of training, to be then done annually.

Fire and life safety documentation has been updated to include access to facility specific evacuation and procedures.  

100% audit of all service plans conducted to include statement to indicate the mental capablity of training retention.

Administrator to ensure all service plans reflect mental capabilty of following fire safety instructions.

Based on observation and interview, it was determined the facility failed to ensure soiled linens and soiled clothing were washed with a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant was used. Findings include, but are not limited to:

A survey of the laundry room on 04/01/24 revealed the facility used a residential washing machine, which did not indicate the water temperature. Soiled linens and clothing were washed with laundry detergent that was identified as lacking a chemical disinfectant. During an interview on 04/02/24, Staff 1 (RN) confirmed that the facility's detergent did not include a disinfecting agent.  

The need to ensure a chemical disinfectant was used when washing soiled laundry was discussed with Staff 1 on 04/04/24. She acknowledged the findings.  

New disinfectent detergent has been ordered and utilized for all resident laundry.

Use of previous laundry detergent has been discontinued.  Disinfectent detergent will be used for all resident laundry.  

Reevaluation of disinfectent detergent to take place if current product becomes no longer available or out of stock.

Administrator and housekeeping supervisor to ensure proper detergent is in supply at all times.     

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

Refer to C295, C420, C422, and C530.

*see C295, C420, C422 and C530

Based on interview and record review, it was determined the facility failed to ensure documentation of completion of 16 hours of annual inservice training for 2 of 2 direct care staff based on their date of hire, and documentation of annual infectious disease training for 2 of 2 long-term staff. Findings include, but are not limited to:

Staff training records were reviewed with Staff 7 (Staffing Director) at 10:58 am on 04/03/24. The following was identified:

a. There was no documented evidence Staff 14 (CG), hired 11/14/21, and Staff 9 (MT), hired 07/19/21, completed the required minimum of 16 hours of annual inservice training, including ten hours related to CBC care, six hours related to dementia care, and infectious disease training, based on their annual date of hire.

b. There was no documented evidence Staff 3 (CG), hired 07/27/21, and Staff 13 (Housekeeper), hired 07/19/21, completed the required annual infectious disease training.

The need to ensure documentation of required annual inservice training was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Annual infection control inservicing has been added to inservice agenda.  All staff to complete on or before 5/31/24.   Going forward, all inservice agendas will include documentation of length of training.

Documentation for staff training to be updated to included length of time for each training.  Annual infection control training added to inservice requirments.

Administrator will evaluate length of  inservices on a monthly basis to ensure 16 hours of training are met.

Adminstrator and Staffing director to track all montly inservices for quantity and content on a montly basis.  

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

Refer to C252, C260, C270, C303, C305, C310, C330, and C340.

*See C252, C260, C270, C303, C305, C310, C330 and C340

Based on observation, interview, and record review, it was determined the facility failed to ensure documentation of an individualized nutritional plan in the residents' service plans for 2 of 3 sampled residents (#s 1 and 2) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:

Observations were made, interviews were conducted, and service plans were reviewed for Residents 1 and 2 during the survey. Both service plans lacked individualized nutrition and hydration information including resident's preferences and needs during waking hours.

In an interview on 04/04/24, Staff 1 (RN) confirmed Resident 1 and 2's service plan lacked documentation of an individualized nutrition and hydration plan.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 on 04/04/24. She acknowledged the findings.

Resident 2: Individualized nutrition and hydration plans have been added to service plan.  Resident 1 has discharged from facility.   

100% audit of resident service plans to ensure individual nutrition and hydration preferences are reflected.  

Service plans to be assessed at each move in and quarterly for individualized preferences and accuracy.

Administrator and/or designee to montior for continued accuracy.  

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations were completed and activity plans were developed for each resident based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3, and 4) whose service plans were reviewed. Findings include, but are not limited to:

Observations were made, interviews were conducted, and service plans were reviewed for Residents 1, 2, 3, and 4 during the survey. Residents 1, 2, 3, and 4's evaluations revealed the facility had not evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities which could be used as behavioral interventions, if necessary.

In an interview with Staff 1 (RN) on 04/04/24, she confirmed the facility did not have documented evidence that individualized activity plans were developed for each resident based on their activity evaluation.  

The need to ensure an activity evaluation and activity plan was developed based on the activity evaluation was discussed with Staff 1 (RN) on 04/04/24. She acknowledged the findings.

Residents 2, 3 and 4:  Service plans updated to reflect current activity, emotional and social needs.  Resident 1 discharged from facility.

100% audit of all service plans to reflect each resident's current activity, emotional and social need.  

Resident services plans will be evaluated at move in and quarterly thereafter to ensure individualized plans are in place.

Administrator and/or Activity director to evaluate services plans for ongoing accuracy and individualized plans.