Print Inspection: WWF4

The findings of the relicensure survey, conducted 03/22/22 through 03/23/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/23/22, conducted 06/22/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:

Observations made on the memory care unit between 03/22/22 and 03/23/22 revealed there were no group activities occurring. Several residents who were in the common areas were not provided any individual or group activities.

Residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. A resident was observed pacing the halls frequently without being engaged in any individual or group activities.

During an interview on 03/23/22, Staff 1 (Administrator) stated there was "no activity calendar or schedule and the facility was working on ..."  providing dedicated activity staff. He further stated, the direct care staff conducted one on one activities as time allowed between resident care and MT duties.

Interviews on 03/22/22 with multiple facility staff revealed there were no activity staff assigned to the memory care unit to conduct activities on the unit. An activity staff from the skilled facility next door provided games, puzzles, pictures for coloring, etc. for direct care staff to engage in one on one activities as time allowed. There were no exercise or group activities provided and the activities identified in multiple sampled resident service plans were not provided.

The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental, and psychosocial needs was discussed with Staff 1 (Administrator) on 03/22/22. He acknowledged the findings.

1. The following actions have been taken to correct each violation:

RCF Administrator and Activity Director to develop monthly calendar to include required elements of daily activity, activity director will ensure maintained ongoing monthly.

Review current resident service plans for activity preferences and review current activity schedule and supplies available at facility.

2. To prevent this violation from occuring again, the:

RCF Administrator has inserviced Activity Director on calender needs and daily coordination of group and individual activities, per resident preferences.

Marquis Activity Consultant has inserviced and worked with Activity Director on calendering and activity program.

RCF Administrator and Activity Director will meet monthly for acuity program development.

The RCF Administrator will provide additional training to caregivers for: importance of activities, location of activity materials, posted activity calendar, and cleaning of activities before and after use.

3. The area needing correction will be evaluated weekly by RCF Administator, or designee for four weeks, and then quaterly for 90 days, to ensure ongoing compliance.

4. The RCF Administrator, or designee will be responsible to see that the corrections are completed and monitored.  

Based on observation, interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (# 1) whose MAR and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 8/2021 and had diagnoses which included dementia.

Resident 1 had an order for PRN Morphine Sulfate Solution (narcotic analgesic) 20 mg/ml, 0.25 ml sublingually every two hours for pain.

On 03/22/22, observation of the Morphine bottle revealed there was 16/ ml in the bottle. The Controlled Substance Disposition Log noted 18.50/ ml in the bottle.

Additionally, Resident 1's Controlled Substance Disposition Logs and MAR, reviewed from 03/01/22 - 03/22/22, documented the following:

* Five occasions staff signed on the drug disposition log that the PRN Morphine was given. However, the MAR lacked documentation the resident received the PRN medication.

On 03/22/22, Staff 6 (MT), reported the discrepancy between the 16 ml and 18.50 ml noted on the log had previously been reported to the RN.

Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 03/22/22. Staff 1 and 2 conducted an investigation of the discrepancy in the medication count and of the inconsistencies between the MAR and Controlled Substance Disposition Log.

On 03/23/22, Staff 1 and 2 acknowledged the facility needed to revise their system for how they tracked and audited controlled substances.

1. The following actions have been taken to correct this violation:

* Resident 1 - MAR and Narcotic count book has immediately reconciled to reflect accurate documentation.

2. Health Services Director RN will meet with each medication assistant and provide retraining for narcotic documentation and administration procedure.

*Health Services Director RN to reeducate and in-service Medication Technicians staff on company protocol for reporting discrepancies timely, and to appropriate reporting channels.  

2. To prevent this violation from occurring again, the Health Services Director will review narcotic log and Medication Administration Record (MAR) for discrepancy on a weekly basis for 4 weeks then monthly for 90 days.

4. Health Services Director RN will be responsible for ensuring the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff  (#s 6, 8, and 9)  had completed first aid/abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Facility staff training records were reviewed with Staff 1 (Administrator) on 03/22/22 at 2:00 pm and revealed the following:

Staff 6 (MT), hired on 11/08/21, Staff 8 (CG) hired on 09/21/21, and Staff 9 (CG), hired on 01/26/22, did not have documented evidence first aid/abdominal thrust training was completed within 30 days of hire.

The need to ensure staff had documented evidence of first aid/abdominal thrust training within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 03/23/22. They acknowledged the findings.

1. The following actions have been taken to correct this violation:

* RCF Administrator and HR Director to complete audit of all current staff files for required elements of training, First aid, and adbominal thrust.

* Staff 6, 8, and 9 have completed First aid and abdominal thrust training.

*Administrator will ensure RCF staff have completed First Aid and abdominal thrust training.  

2. To prevent any future deficient practicies, the following actions will be taken:

* All new employees will be required to complete Abdonminal Thrust training witthin the first 30 days of hire.  

3. RCF Administrator, HR Director, or designee, will review employee file compliance on a weekly basis for 90 days, then quaterly after. HR Director will conduct new hire file audit within 30 days of hire date. Findings will be incorporated and reported in facility monthly Quality Assurance program.

4.HR Director will be responsible to see that corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months of  fire drills. Findings include, but are not limited to:

On 03/22/22, facility fire drill and fire and life safety records, from 07/28/21 through 02/03/22 were reviewed.   Fire drills were not being conducted every other month as required. The fire drills that were conducted quarterly lacked the following required components:  

* Escape route used;

* Number of occupants evacuated;

* Problems encountered and comments related to residents who resisted or failed to participate in the drills was not documented; and

* Documentation the facility provided fire and life safety instruction to staff on alternate months from fire drills.

The need to ensure fire drills were conducted every other month which included all  required components and life safety instruction was provided to staff on alternate months was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director) on 03/23/22. They acknowledged the findings.

1. The following actions will be taken to correct the violation of this rule:

*Fire and Life Safety Training will be conducted on an every other month basis.

*Maintenace Director will complete Fire Drill Evaluation to assess the following areas:

- Escape route used;

- Number of occupants evacuated;

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

2. To ensure the violation does not occur again, Fire and Life Safety Training will be included every other month during scheduled all-staff meetings.

Maintenance director has been inserviced on the requirements for Fire and life safety instruction training requirements.

3. Campus Administrator, or designee, will audit every other month for 90 days to ensure compliance.

Maintenance Director will report montlhy of emergency drills completed to the facility Quality Assurance Committee.

4. The Maintenance Director will be responsible to ensure corrections are complete and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code and residents were provided fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:

On 03/22/22, facility fire drill and fire and life safety records, from 07/28/21 through 02/03/22 were reviewed and lacked the following components:

* Alternate escape routes were used during fire drills;

* Documentation of problems encountered with residents who declined to participate, and changes made to ensure the evacuation standard was met; and

* Documented evidence residents were instructed on fire and life safety procedures within 24 hours of admission and training on fire and life safety was provided to residents annually.

The need to ensure alternate escape routes were used during fire drills, documentation of problems encountered with residents who declined to participate and residents were instructed on fire and life safety procedures within 24 hours of admission and fire and life safety training was provided to residents annually was discussed with Staff 1 (Administrator ) on 03/23/22. He acknowledged the findings.

1. The facility will review and update current fire drill according to Oregon Fire Code (OFC).

The Fire and Life Safety record form to include required elements as listed in OAR will be implemented. Exception under 411-054-0090 (5)(a) Training of residents, as defined in OAR "This requirement does not apply to residents whose mental capabalities does  not allow for following such instructions." This facility is a secured memory care unit, the residents of this facility are not able to cognitvely comprehend or retain training related to fire and life safety, staff within the unit are trained and will support all residents.

2. To ensure the violation does not occur again, Fire and Life Safety Training will be provided to Resident within 24 hrs of admission. If resident is unable to recall process or is unable to demonstrate understanding when asked, facility will document attempt.

Maintenance director has been inserviced on the requirements for Fire and life safety instruction training requirements.

3. Campus Administrator, or designee, will audit every other month for 90 days to ensure compliance. Maintenance Director will report findings on a monthly basis to Quality Assurance Committee.  

4. The Maintenance Director will be responsible to ensure corrections are complete and monitored.

Based on observation and interview, it was determined the facility failed to ensure exit doors did not include locks that delayed evacuation. Findings include, but are not limited to:

On 03/23/22 at 1:45 pm, the following was observed:

* An exit gate located in the secured courtyard on the right side of the building had a locked handle that required a key to open.

During an interview with Staff 1 (Administrator) 03/23/22 at 2:00 pm, he reported the gate with the locked handle was the only exit from the courtyard.  

On 03/23/22 at 2:00 pm, the need to ensure exit doors did not have locks that would delay evacuation was discussed with Staff 1 (Administrator) and Staff 3  (Maintenance Director). They acknowledged the finding.   

1. Immediately the RCF Administator and Maintanence Director conducted a review of the fire alarm system and found that the exit gate located in the secured courtyard disengages with activation of the fire alarm system to ensure a safe exit.

2. The Maintenance Director will educate the RCF staff on the current mechanism of the facility's electromagnetic locking system as it pertains to the exit gate located in the secured courtyard.

3. The Maintenance Director will incorporate the checking of the electromagnetic stip deactivation every other month following the facility's fire drills.

4. The Maintenance Director, or designee will be responsible to ensure the corrections are completed and monitored.  

Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and the wall base in the laundry room was continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture. Findings include, but are not limited to:

The facility laundry room was toured on 03/22/22 at 11:00 am and revealed the following:

1.  For soiled linen, there was no flushing rim clinical sink with a handheld rinsing device.

During an interview with Staff 10 on 03/33/22, she reported  the facility did not have a flushing rim clinical sink with a handheld rinsing device for handling soiled linen.

2.  Multiple areas of the floor and wall base in the laundry room were cracked and portions of the wall base were not tightly sealed to the wall.  Portions of the floor and wall base were not sealed and wood was exposed.

The need to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and the wall base in the laundry room was continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that could harbor insects or moisture was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance Director) on 03/23/22.  They acknowledged the findings.

1. The following actions will be taken to correct this violation:

* Campus Administrator will work with Marquis Companies corporate construction company - PDG Construction to install flushing rim clinical sink with handheld rinsing device.

*Campus Administrator will work closely with Resource Flooring to obtain a bid to replace the flooring and schedule replacement as supply chain and labor allow. will install new flooring that is continuous and cove with the floor and tightly sealed to the wall.

2. To prevent system failure, the Maintence Director will conduct routine examination of the physical plant on a biweekly basis. Findings of areas outside of compliance will be addressed timely and discussed at monthly Quality Assurance meeting by Maintenance Director and Quality Assurance Committee.

3. RCF Administrator, or designee will audit the physical plant inclusive of Solid Linen Room on a weekly basis for 90 days.

4. The RCF Administrator will be responsible for ensuring corrections are completed and monitored.   

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

Observations throughout the survey on 03/22/22 and 03/23/22 revealed two exit doors to a secured courtyard did not have functioning alarms or other acceptable system to alert staff when residents exited the building.  The doors had alarms installed but were not functioning consistently and required repair.  

The need to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building was discussed with Staff 1 (Administrator ) and Staff 3 (Maintenance Director) on 03/23/22. They acknowledged the findings.

1. Maintenance Director to install new door chimes on both doors leading to the secured courtyard.

2. RCF Administrator to inservice RCF staff on use and purpose of door chime to secure courtyard, to allow residents free access to secured courtyard.

RCF Administrator to add signage that will instruct staff on alert chime process and location of door chime.

RCF staff instructed to report faulty or nonworking chime to RCF Administrator immediately.

3. RCF Administrator, Maintenance Director, or designee will monitor functions of door chimes daily for four weeks, then monthly thereafter.

4. The RCF Administrator will be responsible for ensuring the corrections are completed and monitored.   

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: C 242, C 372, C 420, C 422, C 513, C 530 and C 555.

This will be addressed in POC

refer to C242, C372, C420, C422, C513, C530, C555

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 6 and 8) completed all required pre-service training prior to providing direct care to residents, 3 of 3 staff (#s 6, 8 and 9) had demonstrated competency in all required areas within 30 days of hire, and 2 of 2  sampled long term direct care staff (#s 10 and 7) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

1. Staff 6 (MT), hired on 11/18/21 and Staff 8 (CG), hired on 09/21/21, lacked documentation of completion of pre-service dementia training in all required areas prior to beginning performance of job duties.

2. Staff 6, Staff  8, and Staff  9 (MT), hired on 01/26/22, lacked documented evidence demonstrated competency in all required areas was completed within 30 days of hire. Documented evidence of demonstrated competency was lacking in the following areas:

*Role of service plans in providing individualized care;

*Providing assistance with ADL's;

*Changes associated with normal aging:;

*Identification,documentation and reporting changes of condition;

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

*General food safety, serving and sanitation.

3. Staff  7 (CG), hired on 01/14/19 and Staff 10 (CG), hired on 08/25/14, lacked documented evidence 16 hours of annual training related to provision of care, which included six hours of dementia care was completed.

The need to ensure newly hired staff completed all required pre-service training prior to providing care and demonstrated competency in all required areas was discussed with Staff 1 (Administrator) on 03/23/22 at 10:00 am. He acknowledged the findings.

1. RCF Administrator and Health Services Director to develop annual training schedule to meet training requirements and tracking sheet for required elements of training.

2.All RCF staff will be required to sign up with Oregon Care Partners for completion of required dementia training that will be outlined in annual schedule.

All staff will continue to meet monthly to complete chronic disease training during all staff meeting.

3. RCF Administrator and HR Director to audit all current staff files for proof of competency completed. Those found to not be in compliance will be retrained by Health Services Director and RCF Administrator to ensure competency completed. This will be completed weekly for 30 days, then monthly thereafter.

4. HR Director to complete audit of all new hires going forward winthin 30 days of hire date and report missing elements of training to RCF Administrator. HR Director will also report findings to Quality Assurance Committee.  

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: C 302.

This will be corrected in POC for C302

Refer to C302

Based on observation and interview, it was determined the facility failed to ensure the residents had access to an outdoor secured area which allowed residents to enter and return without assistance. Findings include, but are not limited to:

* On 03/22/22 at 10:00 am, two exit doors to the outdoor courtyard area were observed to be locked.  A staff member unlocked one of the doors upon surveyor request. The other door was observed to be locked throughout the rest of the day.

*  03/23/22 one door was observed to be unlocked throughout the day. The second door was observed to be locked throughout the day.

During an interview on 03/22/22 at 3:00 pm, Staff 12 (MT), reported  the doors were supposed to be kept locked and if residents wished to go outside, a staff member would assist them.

During an interview on 03/23/22 at 11:00 am, Staff 1 (Administrator) stated that one of the doors was being kept locked at all times due to the alarm needing to be repaired.

The need to ensure the residents had access to an outdoor secured area which allowed residents to enter and return without assistance was discussed with Staff 1 03/22/23 and 03/23/22. He acknowledged the findings.

1. RCF Administrator to provide inservice to review resident rights to outside areas, and instruction on use of locks on courtyard door to all RCF staff.

RCF Administrator to ensure all staff is knowledgable that exit doors must remain unlocked for residents.

2. RCF Administrator, or designee will ensure staff members are aware of residents rights regarding assess to outside areas.

Resident Rights will be reviewed with new hires during the Pre-Day One process.

3. RCF Administrator will check weekly for 90 days, and monthy thereafter.

4. The RCF Administrator, or designee will be responsible for ensuring corrections are completed and monitored.