Print Inspection: ZV45

The findings of the re-licensure survey conducted 03/08/22 through 03/11/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the first re-visit to the re-licensure survey of 03/11/22, conducted 06/01/22 through 06/02/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 second revisit to the re-licensure survey of 06/02/22, conducted 08/15/22 through 08/16/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and  OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

2. Resident 3 was admitted to the facility in 04/2021 with diagnoses including encephalopathy.

Progress notes and temporary service plans reviewed between 01/21/22 and 03/08/22, revealed the following:

On 01/27/22 an MT reported finding two abrasions on the resident's left upper forearm. The facility RN assessed the abrasions and documented in the 01/27/22 progress notes "etiology unknown".

Incident reports were requested on 03/09/22. Staff 1 (ED) and Staff 2 (ED in training) stated there were no incident reports or investigations conducted for the abrasions.

There was no documented evidence the facility had conducted an immediate investigation of the incident in order to rule out abuse or neglect.

The need to ensure injuries of unknown cause were investigated to rule out abuse or neglect was discussed with Staff 1 and Staff 2 on 03/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure investigations of all incidents were thorough and complete and all incidents of suspected abuse or neglect and injuries of unknown cause were reported to the local SPD office in a timely manner for 2 of 2 sampled residents (#s 3 and 5) reviewed with injuries of unknown cause or altercations. Findings include, but are not limited to:

2. Resident 5 was admitted to facility 01/2021 with a diagnosis including dementia.

Review of Resident 5's record noted an unwitnessed fall on 01/27/22 that resulted in a leg fracture. There was no documented evidence how the facility determined an unwitnessed fall on 01/27/22 was not the result of neglect or abuse. This incident was not reported to the local SPD office at the time of the incident.

The need to thoroughly investigate all incidents, to rule out suspected abuse and/or neglect and report to the local SPD office if abuse/neglect could not be ruled out, was discussed with Staff 1 (ED), and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings. A report was filed with the local SPD office and documentation provided before the survey team exited the building.

1) In-Service will be conducted to review policy for reporting state reportable events.

2) Executive Director or Designee will review occurrence reports with Assisted Living Director and/or Facility Nurse each day to determine if event requires immedate reporting according to policy. Injuries from an unknown source to be fully investigated by facility to rule out abuse/neglect. Reported to SPD or AAA as applicable.

3) Daily

4) Executive Director or Designee

Based on interview and record review, it was determined the facility failed to ensure service plans were reflective and included clear direction for staff for 2 of 6 sampled residents (#s 2 and 7), whose service plans were reviewed. Findings include, but are not limited to:

1. Review of Resident 7's 02/02/22 service plan, 02/2022, and 03/01/22 through 03/08/22 MARs and a 03/09/22 interview with Staff 3 (Assisted Living Director) revealed the resident was prescribed Warfarin, a medication used as a blood thinner.

Resident 7's service plan lacked clear direction to staff regarding possible risks associated with taking Warfarin such as:

* Severe bleeding;

* Red or brown urine;

* Severe headache or stomach pain; and

* Joint pain, discomfort or swelling.

The need to ensure service plans included clear direction to staff was discussed with Staff 1 (ED) and Staff 3 on 03/10/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 08/2019 with diagnoses including lymphoma and depression.

The current service plan dated 01/01/22 noted the resident had a history of anxiety and was independent with most ADL's.

During an acuity interview on 03/08/22, Resident 2 was identified as having recent decline related to weight loss and an open area to a wound.

During observations and an interview on 03/09/22 at 9:25 am, Resident 2 was in bed and able to have a conversation. Two half rails were in the "up" position on either side of the bed, and a walker was placed near the resident's bedside. Resident 2 stated s/he was receiving visits from a Hospice nurse who checked on an ankle wound. There were two air "booties" on the floor and the resident stated s/he did not understand how to wear them and preferred not to wear them.

Upon review of the service plan, the following areas were not reflective of the resident's current needs and did not provide clear direction to staff:

* Use of siderails;

* Recent weight loss and interventions to address the weight loss;

* Specific food preferences (the plan stated the resident had very specific preferences, but did not provide information on what they were);

* Assistance with bathing and frequent refusals, interventions for refusals;

* Assistance, cuing and encouragement with daily hygiene;

* Use of anti-depressant and anti-anxiety medications;

* Interventions for mood changes (when resident expresses suicidal ideation's); and

* Interventions to maintain skin integrity (pillow between knees, ankle boots).

3. Resident 3 was admitted to the facility in 04/2021 with diagnoses including encephalopathy and dementia.

The current service plan dated 01/22/22 noted the resident had a history of mood and behavior disorders and was independent with most ADL's.

During an acuity interview on 03/08/22, Resident 3 was identified as having had a recent fall and behavior outbursts.

During observations and an interview on 03/10/22 at 11:25 am, Resident 3 was up in his/her recliner and able to have a conversation. A wheelchair was placed near the recliner and a four-wheeled walker was near the kitchenette. The resident stated s/he is able to walk but uses the devices to "keep steady". S/he was unable to recall how long s/he has lived at the facility or a recent fall but displayed some bruises and scabbed areas on his/her arms and the left side of his/her body.

Upon review of the service plan, the following areas were not reflective of the resident's current needs and did not provide clear direction to staff:

* Recent history of falls and fall interventions; and

* A description of behaviors and interventions to attempt when behaviors occur.

The need for the service plan to be reflective of the resident's needs and provide clear instruction for staff to follow was discussed with Staff 1 (ED) and Staff 3 (Assisted Living Director) on 03/10/22. They acknowledged the findings.

1) Service plans updated to reflect resident needs and desires (including Resident #2 and #7). Provided clear instructions on all care needs.

2) Staff training: In-service provided to care staff and Assisted Living Director regarding entire service plan process and updating process, including use of Temporary Care Plans.

3) Review Service Plans weekly for 30 days, then resume quarterly review/revisions.

4) Utilize an interdisciplinary team comprised of: Assisted Living Director, Facility Nurse, Executive Director or Designee, Resident, Family/POA (if resident wishes)

2. Resident 9 was admitted to the facility in 10/2021 with diagnoses including dehydration and metabolic encephalopathy.

The resident's 02/09/22 service plan and temporary care plans were reviewed. Staff 6 (CG) was interviewed on 06/02/22 at approximately 11:40 am. The service plan was not reflective of the resident's current needs or did not provide clear caregiving instruction in the following areas:

* Non-weight bearing status;

* Activity preferences;

* Spiritual and cultural preferences were listed as "epinephrine" (an emergency treatment for severe allergic reactions);

* Resident would call when s/he is ready to get up in the morning;

* Where the resident takes meals;

* Escorts to meals;

* How often staff are to check for toileting needs;

* Bathing schedule;

* Assistance needed in clothing choice;

* History of dehydration;

* Daily trash removal;

* Daily bed making; and

* Mobility device cleaning.

There was no documented evidence Resident 9's service plan had been updated quarterly.

The need to ensure service plans were reflective of the residents' current needs, provided clear caregiving instruction and were updated quarterly was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure service plans were updated within 30 days of move-in, were updated quarterly after move-in, were updated after a significant change of condition, were reflective of the identified needs and preferences of the resident, provided clear direction regarding the delivery of services and were readily available to staff for 4 of 4 sampled residents (#s 8, 9, 10 and 11), whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

1. Resident 11 was admitted to the facility in 04/2021 with diagnoses including anxiety and bilateral leg edema.

The resident's service plan dated 01/01/22 was reviewed, Staff 18 (CG) was interviewed on 06/02/22 at 10:41 am, and Resident 11 was interviewed on 06/02/22 at 1:27 pm. The following issues were identified as inaccurate, not being followed or lacked caregiving instruction:

* Diagnosis of anxiety and treatment;

* Requires assistance with cleaning glasses;

* Information relating to side rails;

* Fall history and interventions;

* Bathing preferences and schedule, level of assistance required for bathing, and bed baths;

* Sleeping preferences;

* Level of assistance needed with personal hygiene;

* Level of assistance needed with nail care;

* Assistance required with washing face;

* Status of continence;

* Incontinence care encouraged in the evening;

* PRN medication use;

* Anticoagulant medication use and what to monitor for;

* Skin issues relating to lower leg edema, bruising and skin tears; and

* Daily trash pickup and bed making.

The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff regarding delivery of services, were updated quarterly and were readily available to staff was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

3. Resident 8 was admitted to the facility in 11/2021 with diagnosis of Type 2 Diabetes.

The resident's 02/15/22 and 05/16/22 service plans and temporary care plans were reviewed during the survey.

The service plan dated 02/15/22 was accessible to staff. The current service plan dated 05/16/22 was not accessible to staff.

Resident 8's 02/15/22 service plan was not reflective or provided clear instructions to staff in the following areas:

* The resident no longer self-administered insulin;

* Cognitive decline; and

* Behavior management.

Resident 8 had a significant change of condition on 05/29/22 related to health decline and diagnosis of subdermal hematoma. There was no documented evidence the service plan was updated after the RN assessment. The facility was able to provide a Temporary Care Plan however, it was not accessible to staff.

4. Resident 10 was admitted to the facility in 03/2022 with diagnoses including hypertension. During the acuity interview on 06/01/22 the resident was identified with weight loss.

Service plans and temporary care plans were reviewed during the survey.

The initial service plan dated 03/24/22 was completed 12 days after the resident was admitted to the facility and had not been updated within 30 days after move-in.

The 03/24/22 service plan was not reflective of the resident's current status and lacked clear instruction for staff in the following areas:

* Customary routines;

* Weight loss interventions; and

* Recent losses.

The need to ensure service plans were accessible, updated within 30 days after move-in and were reflective of the resident's current status was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 (Area Manager) on 06/02/22. They acknowledged the findings.

1. Review of service plans for residents (#8,9,10,11). Families have been contacted to arrange a meeting date. All overdue service plans will be up to date by 7/17/2022.

2. Assuring that coordination of care is taking place (this involves Assisted Living Director, Executive Director, Resident, Facility Nurse, and/or Representive of resident's chosing). Creating a service plan calendar to assure that service plans are being updated accordingly. service plans will be up to date  by 7/17/2022.

3. For the next 30 days, review daily. After this resume weekly monitoring.

4. Executive Director, Assisted Living Director, Facility Nurse

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 7). Findings include, but are not limited to:

Resident 1, 2, 3, 4 and 7's current service plans were reviewed during the survey.

The service plans lacked evidence the resident's or their legal representative's participated in the development of the service plans and were part of the Service Planning Team.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED), Staff 2 (ED in training), Staff 3 (Resident Care Coordinator) and Staff 4 (RN) on 03/10/22. They acknowledged the findings.

1) Assured that all Service Plans have been reviewed and signed by an interdisciplinary team that includes Resident/POA prior to activating.

2) Staff training: In-service provided to Facility Nurse and Assisted Living Director regarding entire service plan process and importance of including all applicable parties in update process.

3) Review Service Plans weekly for 30 days, then resume quarterly review/revisions.

4) Utilize an interdisciplinary team comprised of: Assisted Living Director, Facility Nurse, Executive Director or Designee, Resident, Family/POA (if resident wishes)

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 8, 9, 10 and 11). This is a repeat citation. Findings include, but are not limited to:

Resident 8, 9, 10 and 11's current service plans were reviewed during the survey.

The service plans lacked evidence the resident's or their legal representatives participated in the development of the service plans and were part of the Service Planning Team.

The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 (Area Manager) on 06/02/22. They acknowledged the findings.

1. Review of service plans for residents (#8,9,10,11). Families and residents have been contacted to arrange a meeting date to review service plan.

2. Assuring that coordination of care is taking place (this involves Assisted Living Director, Executive Director, Resident, Facility Nurse, and/or Representive of resident's chosing). Creating a service plan calendar to assure that service planning team is involved. calendar wil include name of person attending, meeting date,time and any declinations to meet for service plan review by family, POA, residents.

3. For the next 30 days, review daily. After this resume weekly monitoring.

4. Executive Director, Assisted Living Director, Facility Nurse

Based on interview and record review, it was determined the facility failed to ensure short term changes were reviewed to determine and document what action or intervention was needed for the resident, communicated the action or interventions to staff and those changes were monitored through resolution for 3 of 4 sampled residents (#s 9, 10 and 11) who experienced short term changes of condition. Findings include, but are not limited to:

1. Resident 9 was admitted to the facility in 10/2021 with diagnoses including cardiomegaly, metabolic encephalopathy and dehydration.

Interview with staff during the survey indicated the resident required staff assistance with all ADLs. The resident's facility record was reviewed and indicated the following falls:

* On 03/18/22 the resident fell out of bed. Interventions directed staff to put incontinent supplies away and to encourage the resident to sleep in the middle of the bed with pillows on both sides of him/her.

* On 04/03/22 the resident rolled out of bed. Interventions directed staff  to put the resident in the middle of his/her bed.

* On 05/17/22 fell out of bed. Interventions directed staff to check on the resident twice per shift, take vitals each shift, remind the resident to call when s/he needs to get out of bed and to place the resident in the middle of the bed with pillows on each side of him/her.

There was no documented evidence the facility monitored the determined actions or interventions needed for the above falls and that the changes of condition were monitored through resolution.

2. Resident 11 was admitted to the facility in 04/2021 and was identified as needing ADL assistance and required two staff members for transfers.   

Progress notes dated 05/30/22 through 06/01/22 and a Resident Occurrence Report dated 05/18/22 was reviewed.

Documentation revealed Resident 11 was found on the floor beside his/her bed at 8:30 pm.

There was no documented evidence the facility determined actions or interventions needed for the change of condition and that this change of condition was monitored through resolution.  

The need to ensure short term changes were reviewed to determine and document what action or intervention was needed for the resident and the changes were monitored through resolution was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

3. Resident 10 was admitted to the facility in 03/2022 with diagnoses including hypertension.

Progress notes, weight records and temporary care plans were reviewed during the survey.

On 05/10/22, Resident 10's weight was recorded as 116 pounds, which was an 11-pound weight loss or 8.66% of total body weight within one month.

A temporary care plan was written that included monitoring instructions to weigh resident one time per week and to ask resident if s/he would like something else if s/he wasn't eating the community meals.

The temporary care plan was not in an accessible location for staff to read.

On 06/01/22, Staff 4 (RN) reported, "we are having a filing issue due to staff filing the temporary care plans in multiple locations where they may not be read by all staff."

On 06/02/22, Staff 14 (MT) reported being aware of Resident 10's weight loss, however, was not aware of any interventions or additional support that was needed.

On 06/01/22, surveyor observed Staff 15 (MT) weigh Resident 10. Staff 15 didn't calibrate the manual chair scale. The resident's weight was recorded as 134 pounds, which reflected an 18 pound increase within one week.

The surveyor requested Staff 4 re-weigh the resident. Staff 4 had the resident stand up and sit back down on the chair scale but failed to calibrate the scale. Staff 4 reported the resident's weight was recorded as 128 pounds, which reflected a 12 pound increase from the previous week.

On 06/02/22, Staff 19 (Regional RN), reported she took the resident's weight, which was 117 pounds. Staff 19 acknowledged the weight variances, lack of training on how to use the scale to effectively monitor residents' weight, lack of implementing interventions for weight loss and reviewing the interventions for effectiveness. Staff 19 also indicated new monitoring instructions to weigh resident twice per week would be implemented and a temporary care plan would be written.

The need to ensure the facility had an effective system to monitor weight changes, review changes of condition to determine and document what action or intervention was needed for the resident and communicated the interventions to staff was discussed with Staff 2 (ED), Staff 19, Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 (Area Manager) on 06/02/22. They acknowledged the findings.

1. Review of progress notes for residents (#9,10,11) Review of wound log, occurrence reports, vital signs from the last 30 days to capture any change of condition. Facility Nurse will evaluate resident and update service plan with appropriate interventions.

2. Facility Nurse, Assisted Living Director, Executive Director will review progress notes, vital signs, occurrence reports, and wound log daily to evaluate need for change of condition assessment. Care staff will be in-serviced regarding change of condition and updating proper management by 7/17/2022.

3. Daily review of resident 'change of condition', progress notes, vital signs and occurrence reports.

4. Executive Director, Facility Nurse, Assisted Living Director are responsible for ongoing monitoring.

Based on interview and record review, it was determined the facility failed to ensure a timely assessment of significant changes of condition by a facility RN with interventions developed and implemented as a result of the assessment for 1 of 2 sampled residents (# 2) who experienced a significant change of condition.  Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2019 with diagnoses including lymphoma and depression.

The clinical record was reviewed, including progress notes, physician's orders, temporary service plans and Hospice notes. Progress notes indicated on 02/04/22 the resident started receiving Hospice services, had experienced a seven pound weight loss in one month (5.25% of body weight) and developed a pressure area on his/her ankle.

The facility RN documented an assessment of the changes of condition on 02/14/22 (ten days following the significant change). The assessment did not include interventions as a result of the assessment for areas including weight loss and skin injury.

The need to ensure significant changes of condition were assessed timely by a facility RN with interventions developed and implemented as a result of the assessment was discussed with Staff 3 (Assisted Living Director) and Staff 4 (RN) on 03/09/22 and with Staff 1 (ED) and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings.

1) Facility Nurse will review and update 'Change of Condition' assessments by 05/10/2022.

2) Facility Nurse will review chart notes, alerts, and occurrence reports daily to evaluate the need for 'Change of Condition' assessments. Care staff in-service provided to educate staff on informing nurse of changes in condition, what to observe/report, and proper documentation.  

3) Daily

4) Facility Nurse and Assisted Living Director - with oversight from Executive Director

2. Resident 9 was admitted to the facility in 10/2021 with diagnoses including hypokalemia, cardiomegaly and hypertension. The resident was identified during the acuity interview on 06/01/22 as having a "weight loss."

The clinical record was reviewed, including progress notes, weight record and temporary care plans.

On 04/07/22, Resident 9's weight was recorded as 119 pounds. On 05/10/22, the resident's weight was recorded as 125 pounds, which was a 5.04% weight gain which represented a significant weight gain.  

The facility RN documented an assessment of the change of condition on 05/24/22 (14 days after the weight gain was identified).

On 06/01/22 at 12:12 pm, Staff 19 (Regional RN) stated no interventions were needed as this was a needed weight gain for the resident.

On 06/02/22 at 10:37 am, observations of the resident confirmed Resident 9 to be thin with little to no bilateral edema (a condition that could be related to the resident's above mentioned diagnoses) noted.

The need to ensure significant changes of condition were assessed timely by an RN was discussed with Staff 2 (ED), Staff 19, Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a timely assessment of significant changes of condition by a facility RN which documented findings, resident status, and interventions made as a result of this assessment for 2 of 3 sampled residents (#s 9 and 10) who experienced significant weight changes. This is a repeat citation. Findings include, but are not limited to:

1. Resident 10 was admitted to the facility in 03/2022 with diagnoses including hypertension. During the acuity interview on 06/01/22 the resident was identified with weight loss.

The clinical record was reviewed, including progress notes, weight record and temporary care plans.

On 05/10/22, Resident 10's weight was recorded as 116 pounds, which was an 11 pound weight loss or 8.66% of total body weight within one month. This represented a severe weight loss.

The facility RN documented an assessment of the change of condition on 05/24/22 (14 days after the weight loss was identified). A temporary care plan was written which included interventions and monitoring instructions however, the care plan was not accessible for all direct care staff to read.

The need to ensure significant changes of condition were assessed timely by a facility RN with interventions developed and implemented as a result of the assessment was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 (Area Manager) on 06/02/22. They acknowledged the findings.

1. Review of progress notes for residents (#9,10). review of wound log, occurrence reports, vital signs from the last 30 days to capture any change of condition. Facility Nurse will correct/complete changes of condintion for residents (#9,10)

2. Facility Nurse, Assisted Living Director, Executive Director will review progress notes, vital signs, occurrence reports, and wound log daily to evaluate need for significant RN/evaluation. Care staff will be in-serviced regarding change of condition and updating proper management by 7/17/2022.

3. Daily review of resident 'change of condition', progress notes, vital signs and occurrence reports.

4. Executive Director, Facility Nurse, Assisted Living Director

2. Resident 1 was admitted to the facility in 01/2019.

Review of the resident's 10/20/21 signed physician orders, 2/2022 and 03/1/22 through 03/08/22 MARs indicated the resident had an order to self-administer Travoprost eye drops. The facility administered all other medications for the resident.

There was no documented evidence a self-medication evaluation had been completed by the facility since 06/12/21.  

The need to ensure a quarterly self-medication administration evaluation was completed for each resident who self-administered medications was discussed with Staff 4 (RN) on 03/09/22 and with Staff 1 (ED) on 03/10/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications, for 2 of 2 sampled residents (#s 1 and 4) who administered their own medications. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility 07/2022 with a diagnosis of diabetes.

During the acuity interview on 03/08/22, Resident 4 was not identified as administering his/her own medications.

Review of the record indicated Resident 4 was self-administering his/her insulin and the evaluation to determine the resident's ability to safely self-administer medications was completed on 08/10/21.

In an interview on 03/09/22, Staff 4 (RN - Health Service Director) stated Resident 4 completed his/her CBG checks and routine daily insulin injections. Staff 4 acknowledged a quarterly self-medication evaluation had not been completed.

The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications was reviewed with Staff 3 (Resident Care Coordinator) and Staff 4 on 03/09/22. They acknowledged the deficiency.

1) All self-medication evaluations with current physican orders will be completed by 5/10/2022, including Resident #1 and #4.

2) Staff training: In-service provided to Assisted Living Director and Facility Nurse regarding Self-Administer Policy.

3) Weekly review for 30 days, then resume quarterly evaluations.

4) Assisted Living Director and Facility Nurse - with oversight from Executive Director

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure ability to safely self-administer medications, for 1 of 1 sampled resident (#10) who administered their own medications. This is a repeat citation. Findings include, but are not limited to:

Resident 10 was admitted to the facility 03/2022 with a diagnosis of hypertension. During the acuity interview on 06/01/22, Resident 10 was identified as administering his/her own medications.

Review of the initial service plan and signed physician orders indicated Resident 10 was self-administering all medications. The facility failed to complete an evaluation to determine if the resident was able to safely self-administer medications until 06/01/22.  

The need to ensure residents who chose to self-administer their medications were evaluated prior to self-administering their own medications and at least quarterly to ensure ability to safely self-administer medications was discussed with Staff 2 (ED), Staff 19 (Regional RN) and Staff 22 (Area Manager) on 06/02/22. They acknowledged the findings.

1. Resident (#10) Review of all overdue assessments and review for updated MD order.

2. Create a calendar for upcoming assessments, assuring that facility acquires MD order quarterly. Facility will obtain signed physician orders for residents identified to be self-Admin. Assisted Director will have all overdue 'Self-Admin' up to date by 7/17/2022.

3. Review 'Self-Admin' assessments daily for 30days, then continue weekly monitoiring.

4. Executive Director, Assisted Living Director

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 1 of 1 sampled residents (#2) with devices with restraining qualities. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2019 with diagnoses including lymphoma. During a tour of the resident's room on 03/09/22, bilateral half-length side rails were observed on Resident 2's hospital bed. The side rails were in the up position and fastened securely to the bed.

In an interview on 03/09/22, Staff 3 (Assisted Living Director) acknowledged the use of the side rails and explained they were used to assist the resident with getting in and out of bed and help prevent unsteadiness. A side rail assessment was requested.

On 03/09/22 at 2:45 pm, Staff 3 provided an assessment for the side rails, dated 03/09/22. There was no previous documentation of a side rail assessment. The assessment was reviewed and did not provide the following required information:

* Whether the resident specifically requested or approved of the device;

* The facility had informed the individual of the risks and benefits associated with the device;

* A facility registered nurse, a physical therapist or occupational therapist had conducted a thorough assessment (the document was not signed);

* Other less restrictive alternatives had been evaluated prior to the use of the device; and

* The facility had instructed caregivers on the correct use and precautions related to use of the device. The use of the side rails was not documented in the resident's current service plan.

The need to ensure all devices with restraining qualities were evaluated quarterly and their use documented in the resident's service plan was reviewed with Staff 1 (ED), Staff 2 (ED in training) and Staff 3 on 03/10/22. They acknowledged the findings.

1) Service plans (including Resident #2) have been updated to reflect support device use, function, and safety information. Maintenance to evaluate that devices are functioning properly. A review of all remaining residents with supportive/restraining devices has been conducted to assure that all assessments completed, signed, and in resident's record.

2) Staff Training: In-service provided to all care staff members regarding device safety, proper use, and what to observe/report with device. Facility Nurse has reviewed policy and rules associated with completing initial/on-going assessments and proper content of assessments.

3) Upon initial use, quarterly, and as needed.

4) Facility Nurse - oversight from Executive Director or Designee

Based on observation, interview and record review, it was determined the facility failed to ensure documentation of the use of supportive devices with restraining qualities was included in the resident's service plan and evaluated on a quarterly basis, for 1 of 1 sampled resident (#11) with devices with restraining qualities. This is a repeat citation. Findings include, but are not limited to:

Resident 11 was admitted to the facility in 04/2021 and was identified during the acuity interview as needing assistance with ADLs and two staff members during transfers. During a tour of the resident's room on 06/02/22, a side rail was observed on the resident's hospital bed. The side rail was fastened securely to the bed.

A side rail assessment was requested on 06/01/22. The assessment provided was dated on 05/30/22 at 11:11 am and lacked the following required information:

* Whether the resident specifically requested or approved of the device;

* The facility had informed the individual of the risks and benefits associated with the device;

* A facility registered nurse, a physical therapist or occupational therapist had conducted a thorough assessment;

* Other less restrictive alternatives had been evaluated prior to the use of the device; and

* The facility had instructed caregivers on the correct use and precautions related to use of the device.

There was no documented evidence an assessment of the side rail was completed prior to 05/30/22 and the use of the side rail was not documented in the resident's current service plan.  

The need to ensure all devices with restraining qualities were evaluated quarterly and their use documented in the resident's service plan was reviewed with Staff 2 (ED), Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

1. Resident (#11) RN evaluation will be completed by 7/17/22. primary doctors advice to include PT/OT for review of supportive devices will be aquired if not already on PT/OT services.

2. Create a calendar for upcoming assessments, assuring that facility acquires MD order quarterly. Facility Nurse will have all overdue 'Supportive Devices' up to date by 7/17/2022.

3. Review 'Supportive Devices' assessments daily for 30days, then continue weekly monitoiring.

4. Executive Director, Facility Nurse

Based on interview and record review, it was determined the Administrator failed to show documented evidence of a Residential Care Facility Administrator license and failed to have 20 hours of documented, Department-approved continuing education credits each year. Findings include, but are not limited to:

a. On 03/08/22, Staff 1 (ED) was asked to provide documentation of her Residential Care Facility Administrator license. Staff 1 revealed she had not obtained her license.

b. Staff 1 was also asked to provide documentation she had completed 20 hours of continuing education credits (CEUs) annually. Staff 1 stated she had completed continuing education credits related to her Administrator license in Washington state and revealed she did not have the required 20 hours of Division - approved training.

The requirement to have a current Residential Care Facility Administrator license and 20 hours of documented continuing education credits each year was discussed with Staff 1 and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings.

1) Administrator will have all licensing requirements completed by 05/10/2022.

2) Re-education has been provided to Administrator regarding licensure requirements.

3) Administrator will assure that all licensing requirements have been completed before renewal date.

4) Administrator

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 10 and 11 ) completed all required pre-service training including dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Facility training records were reviewed on 03/10/22. Staff 7 (CG), hired 01/19/22, Staff 10 (CG) hired 02/03/22 and Staff 11 (Med Aide) hired 01/02/22 lacked documented evidence of completing any pre service training prior to beginning job duties.

The need to ensure direct care staff completed all required pre-service training prior to beginning their job responsibilities was reviewed with Staff 1 (ED) and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings.

1) 'Pre-Service Orientation' for current employees will be completed and up-to-date by 04/11/2022. New hires after this date will attend orientation prior to training.

2) Review employee training requirements weekly. All new hires will be required to attend orientation prior to training.

3) Weekly

4) Executive Director or Designee, Assisted Living Director, and Office Manager

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (#18) completed all required pre-service orientation training and pre-service dementia training prior to beginning their job responsibilities. This is a repeat citation. Findings include, but are not limited to:

Facility training records were reviewed on 06/01/22. Staff 18 (CG), hired 05/09/22, lacked documented evidence of completing all required elements for pre-service orientation and pre-service dementia training prior to assuming job duties.

The need to ensure direct care staff completed all required pre-service training including pre-service dementia training prior to beginning their job responsibilities was reviewed with Staff 2 (ED), Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

1. Review of employee (#18) training records to assure that all are current, new hire Orientation and Pre-Service Dementia completed before next scheduled work day. This will be completed for all employees by 7/17/2022.

2. Create an employee matrix to assist with monitoring required items for employees upon hire and ongoing. Update weekly.

3. Review daily for 30days, then weekly monitoring after.

4. Executive Director, Office Manager

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 7 and 11) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 03/10/22 revealed Staff 7 and Staff 11 (CG's), hired 01/19/22 and 02/03/22 respectively, lacked documented evidence of demonstrated competency within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation; and

* First Aid/abdominal thrust.

The need to ensure all direct care staff demonstrated competency in all required training topics within 30-days of hire was discussed with Staff 1 (ED) and Staff 2 (ED in training). They acknowledged the findings.

1) Assure that all current employee's have proper documentation of competency demonstration in all required areas by 05/10/2022.

2) An audit was completed on remaining staff to verify compliance with training requirements and associated documentation.

3) Re-education has been provided to those responsible for overseeing the training process/training documentation to assure understanding of rule and community policy requirements.

4) Executive Director or Designee will oversee on-going compliance through audits of training materials upon completion of the initial training process and at least twice monthly thereafter.

Based on interview and record review, it was determined the facility failed to have documented evidence the required 12 hours of annual in-service training, including 6 hours of dementia care training was completed for 2 of 2 long-term staff (#s 12 and 13) whose training records were reviewed. Findings include, but are not limited to:

Review of staff training records on 03/10/22 indicated the following:

There was no documented evidence that Staff 12 (CG) and Staff 13 (CG) completed 12 hours of annual in-service training on topics related to provision of care in CBC setting, including 6 hours of annual training on dementia care.

The need to ensure annual in-service training was completed by all direct care staff was discussed with Staff 1 (ED) and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings. They acknowledged the findings.

1) Annual training for all staff with at least one year of employment to be current by 05/10/2022.

2) An audit was completed to verify compliance with on-going annual training requirements for staff with atleast one year of employment with community. Staff requiring annual training have been in-serviced to review requirements.

3) Review employee training requirements weekly.

4) Assisted Living Director - with oversight from Executive Director

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

Review of fire drill and fire and life safety records for 10/2021 through 03/2022 identified the following deficiencies:

1. Fire and life safety instruction for staff was not being conducted and documented on alternate months of the fire drills;

2. The records lacked documentation of the following required components:

* Escape route used;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

The need to ensure the facility conducted fire drills and provided fire and life safety instruction to staff on alternate months, and included all required documentation was reviewed with Staff 1 (ED) and Staff 2 (ED in training) on 03/10/22. They acknowledged the findings.

1) Fire Drills to be completed, including evacuation route and documentation regarding required resident evacuation by 05/10/2022.

2) Fire Drills will be reviewed for completion routinely to assure that shifts are rotated and forms are filled out completely for each drill. Resident and staff In-services to be provided per community schedule

3) Monthly

4) Maintenance Director and Executive Director

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

Fire drill records for 05/2022 through 06/2022 were reviewed during the survey.

1. The facility's fire drill records lacked documentation of the following required components:

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

2. Fire and life safety training records were requested on 06/02/22 and Staff 2 (ED) confirmed that there was no clear system in place for continued fire and life safety training on alternating months.

The need to ensure the facility conducted fire drills, provided fire and life safety instruction to staff on alternate months and included all required documentation was reviewed with Staff 2, Staff 19 (Regional RN), Staff 22 (Area Manager) and Staff 23 (Owner) on 06/02/22. They acknowledged the findings.

1. Review fire/life safety with all current staff. Provide an in-service regarding their role in the event of a fire/evacuation. in-service will include the number of staff and residents evacuated to safety durign drill. Map will include all safe zones to where residents and staff will evacuate in the event of a fire.

2. Create a calender for monthly All-Staff training to include alternating fire/life safety requirements. Fire drill calender will be created for management staff to prepare appropriately. Executive Director and Office Manager will review documentation to assure that all require components are present.

3. Monthly

4. Executive Director, Maintenance Director

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire drill records from 10/2021 through 03/2022 were reviewed. The records lacked required documentation of the following:

* Evidence alternative routes were used during fire drills; and

* Staff interviewed knew the designated point of safety.

Staff 2 (ED in training) and Regional supports were interviewed on 03/10/22 and stated the facility would be implementing a procedure to add a map to the documentation showing the escape route used and and that staff knew the designated point of safety.

The need to provide fire and life safety and provide the required documentation was discussed with Staff 1 (ED) and Staff 2 on 03/10/22. They acknowledged the findings.

1) Fire Drill forms have been reviewed for completion and accuracy. Executive Director and Maintenance Director have reviewed community policy and all associated rules for fire drills and documentation.

2) Staff training: In-service to be provided monthly for three months to assure that staff know their role, evaucation routes, and proper fire safety.

3) Staff education regarding Fire Drills and Safety will be provided monthly for three months, then resume routine review.

4) Maintenance Director and Executive Director

Based on observation, interview and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C260, C262, C280, C325, C340, C370, C374, C420, C615

1. Plan of Correction binder has been created and tabbed out for each citation/tag. Each section will include progress made toward compliance. Updated daily and as needed.

2. Executive Director will review Plan of Correction with all members of management team daily to assure tasks are being completed.

3. Daily

4. Executive Director

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 03/02/22 and 03/10/22. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident bedrooms lacked a system which limited how much the window could be opened to prevent accidental falls.

Some windows in the common areas had window locks installed which prevented the windows from opening fully. The following window locations were observed and did not have such window devices installed:

* Common area laundry room near room 206;

* Resident Unit 256 bedroom;

* Resident Unit 212 bedroom; and

* Common area top of stairwell on second floor.

In an interview with two unsampled residents on 03/10/22, both resident's stated they had windows in the bedrooms that could open fully and would open their windows in the warmer months for fresh air.

The lack of a mechanism to prevent accidental falls was discussed with Staff 2 (ED in training) on 03/08/22 and with Staff 1 (ED) on 03/10/22. Staff 2 stated additional window devices had been added to some the common area windows but had not done a full review of all windows on the second floor.

1) All operable windows above the first floor have been equipped with lock designed to prevent falls.

2) Locks to be checked and maintained per community policy by Maintenance Director.

3) Routine maintenance checks to be completed per community policy to assure locks are functioning properly.

4) Maintenance Director - with oversight from Executive Director

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 06/02/22. Resident unit windows on the second floor opened vertically, and windowsills were lower than 36 inches. The windows in common areas and resident bedrooms had a system which limited how much the window could be opened however the locking mechanism was easily unlocked which allowed for the windows to be fully opened.

The following random sample of second floor windows throughout the facility were observed to open fully:

* Common area laundry room near room 206;

* Resident Unit 205 bedroom and living room;

* Resident Unit 208 bedroom and living room;

* Resident Unit 253 bedroom and living room;

* Resident Unit 274 bedroom and living room; and

* Common area library.

In an interview on 06/02/22, Staff 22 (Area Manager) confirmed all the windows had the same design with locking mechanisms that could be unlocked. The maintenance director had taken a count of all second floor windows and was going to purchase a different locking mechanism that would limit how much the windows could be opened.

The lack of an operable locking mechanism to prevent accidental falls from windows above the first floor and lower than 36 inches from floor to sill was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 on 06/02/22. They acknowledged the findings.

1. Executive Director and Maintenance Director will walk-through 2nd floor and check all windows for appropriately locking systems by 7/17/2022.

2.  Maintenance Director will check monthly and as needed to assure the locking systems are working appropriately.

3. Monthly

4. Executive Director, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the stove in the activity room, located on the second floor had a keyed, remote switch or safety device to ensure staff control.  Findings include, but are not limited to:

The environment was toured on 06/02/22 and revealed the stove in the activity room located on the second-floor was able to be turned on without the use of a key, remote switch or other safety device.

During an interview with Staff 22 (Area Manager) on 06/02/22, it was reported there was a keyed switch in a lockable cabinet above the stove. She reported it was not being used by staff, the lock needed to be replaced and keys provided to staff.

The need to ensure the stove in the second floor activity room had a functioning keyed, remote switch or other safety device was discussed with Staff 2 (ED), Staff 19 (Regional RN), Staff 20 (Regional Health Services Director), Staff 21 (Owner) and Staff 22 on 06/02/22. They acknowledged the findings.

1. Ordered a lock (with key), repair stove by 7/17/2022

2. Maintenance Director will assure that lock is working monthly and as needed.

3. Monthly

4. Executive Director, Maintenance Director