Pacific Living Centers of Bend

Based on observation, interview, and record review, it was determined the facility failed to ensure food was handled, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
Observations of the facility kitchen, food storage areas, food preparation, and food service with Staff 1 (Regional Director of Operations) on 10/11/24 revealed:

* There were undated and unlabeled foods in the refrigerators.
* Expired foods were identified in the refrigerators.
* Multiple food containers were stacked on the refrigerator shelves preventing air circulation.
* The carpet in the pantry closet was damaged exposing uncleanable bare wood.
* Spoons were left in containers of food in the pantry closet.
* Foods were stored in the garage on shelving along with re-usable incontinence pads.
* The testing strips were available to ensure the sanitizing solution was at the correct ratio were damaged. The sanitizer towel was not submerged in the sanitizing solution. There was no documented evidence the sanitizer solution was tested to ensure correct ratios.
* There was no evidence cooked food temperatures were consistently monitored.
* Universal Workers preparing and serving food were observed without hair and beard restraints.
* Universal Workers preparing and serving food were observed to not wash hand upon entering the kitchen.
* Universal Workers who provided incontinent care to residents were observed to prepare and serve food with out donning aprons.

An uncovered frying pan of cooked food was noted on a cold stove. An uncovered bowl of cut melon was observed on the kitchen counter.
Food was observed to be re-heated in the microwave without testing the temperature to ensure it reached 165 degrees F (Fahrenheit).
There was no system in place to ensure hot foods were maintained at 135° F or above and cold foods maintained at 41° F or below when being served.

The food handling and storage findings were reviewed with Staff 1 on 10/11/24. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

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 240.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

The findings of the re-licensure survey, conducted 03/25/24 through 03/26/24, are documented in this report. The survey was conducted to determine compliance with 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 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the re-visit to the re-licensure survey of 03/26/24, conducted on 08/12/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure resident altercations were reported to the local SPD office for 1 of 1 sampled resident (#1) who was involved in altercations. Findings include, but are not limited to:Resident 1 was admitted to the facility in August 2023 with diagnoses including Wernicke's Encephalopathy, a form of dementia. The resident's service plan, dated 03/07/24, behavior plan, and interviews with care staff between 03/25/24 and 03/26/24 indicated the resident ambulated independently throughout the facility and was aggressive and agitated at times.Facility Progress Notes were reviewed and noted:* 01/28/24 - "After dinner [Resident 1] proceeded to pick on [resident room number] again. [S/he] began shoving the side table over toward [room number]...and unplugging [his/her] chair..." Staff explained Resident 1 unplugged an electric recliner, restricting the other resident.* 03/04/24 - "Resident came out of [his/her] room raising [his/her] voice at [room number] to move. [Resident 1] stated "If you don't move I'm going to beat your ass! Move now! Staff attempted to redirect by informing [Resident 1] there were 6 other available seats in the living room to which [Resident 1] stated [s/he] didn't care...[Resident 1] grabbed a coffee cup intending to throw coffee on [room number]. The cup happened to be empty and [Resident 1] then grabbed a cup of juice to throw on [room number] which staff took from [him/her]..."In an interview with Staff 1 (Regional Director of Operations) on 03/26/24, she explained the incidents had not been reported to the local SPD.The need to ensure incidents of threatening significant physical harm and intimidation were reported to the local SPD was reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the findingsThe facility was asked to report the incidents. Case intake numbers were provided prior to survey exit.

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 2 of 2 sampled residents (#s 2 and 3) whose medications, MARs, and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:1. Resident 2 was admitted in 03/05/24 with diagnoses including pain.Resident 2 had an order for Hydrocodone/APAP 5-325 mg one tablet every six hours as needed for severe pain.Review of Resident 2's Controlled Substance Disposition Logs and MARs, from 03/01/24 to 03/26/24, and pills, revealed 11 occasions when staff signed on the drug disposition log the medication was given, however, the MAR lacked documentation the resident received the medication. The medications were in a bottle and the count matched the dispensation log.The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the discrepancies.2. Resident 3 was admitted to the facility in May 2023 with diagnoses including dementia and anxiety.Resident 2 had an order for Lorazepam 0.5 mg one tablet every six hours as needed for anxiety.Resident 2's Controlled Substance Disposition Logs, medication bubble packs, and MARs, reviewed from 03/01/24 to 03/26/24, revealed the medication was documented on the MAR as administered on 03/07/24. There was not documentation of the medication being given on the Controlled Substance Disposition log. The Disposition Log and medication in the bubble pack count matched. The inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (Regional Director of Operations) on 03/26/24. She acknowledged the discrepancies.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused consent to an order, for 1 of 1 sampled resident (#1) with multiple medication refusals. Findings include, but are not limited to:Resident 1 was admitted to the facility in August 2023 with diagnoses including Wernicke's Encephalopathy, a form of dementia.Resident 1's MARs from 03/01/24 through 03/25/24 were reviewed. Resident 1 refused some or all medications on 16 days.There was no documented evidence each incident of Resident 1's multiple medication refusals had been reported to the practitioner. The need to notify the practitioner when Resident 1 refused ordered medications was reviewed with Staff 1 (Regional Director of Operations). She acknowledged the physician had not been informed of the refusals.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common areas were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:A tour of the facility on 03/25/24 revealed the following:* The shared bathroom in the common area had water that when turned on, was hot to the touch. The hot water temperature, taken by the surveyor with the facility digital thermometer, was 125 degrees Fahrenheit; and* Various residents' bathroom sinks' hot water was between 123 and 125 degrees Fahrenheit.Signs were posted at all sinks warning of hot water.In an interview with Staff 1 (Regional Director of Operation) on 03/25/24, she reported the facility had identified the issue and had been adjusting the temperature. She acknowledged the water temperatures were exceeding 120 degrees Fahrenheit.

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 231 and C 545.

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 C 302 and C 305.

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height. Findings include, but are not limited to: The facility was toured on 03/25/24. Sections of fencing surrounding the perimeter of the outdoor recreation area did not meet the six foot height requirement. The surveyor measured several sections of the fence. Measurements included areas as low as 63 inches, or five feet three inches, in height.The facility had cameras to monitor the courtyard. The door alerted staff when residents exited the facility into the courtyard. The need to ensure fences surrounding the perimeter of the outdoor recreation area were no less than six feet (or 72 inches) in height was discussed with Staff 1 (Regional Director of Operations) on 03/25/24 and 03/26/24. Staff 1 reported a fencing company was scheduled on 03/27/24 to increase the height of the fence.

The findings of the kitchen inspection, conducted 07/19/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 07/19/22, conducted 10/20/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review and interview, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation and food service on 07/14/22 revealed:* Splatters, spills, drips, and debris noted: - Interior of Refrigerator Two; - Shelving throughout kitchen and in dry storage area; - Interior of the oven; - Walls; - Interior of drawers, cupboards and cabinets; and - The drawer, cupboard, and cabinet handles and surfaces were sticky to the touch.* Undated and unlabeled food in Refrigerator Two;* Open food items in Freezer Two; * Damage to the door jambs and floor boards creating an un-cleanable surfaces; and* No small diameter probe thermometer to measure thin foods.The food storage concerns and areas in need of cleaning and repair were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

The findings of the re-licensure survey, conducted 06/16/21 through 06/17/21, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a dayA situation was identified where there was a failure of the facility to comply with the Departments rules that was likely to cause a resident serious harm. An immediate plan of correction was requested in the following area:OAR 411-054-0025 (1) Facility Administration: OperationOAR 411-054-0045 (1)(f)(B) RN Delegation and TeachingOAR 411-054-0055 (1)(a) Systems: Medications and TreatmentsThe facility put an immediate plan of correction in place during the survey and the situation was abated.
The findings of the first re-visit to the relicensure survey of 6/17/21, conducted 9/15/21 through 9/16/21, 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. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the second re-visit to the re-licensure survey of 06/17/21, conducted 12/13/21, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 6/16/21 through 6/17/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in report.
Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. This is a repeat citation. Findings include, but are not limited to:During the re-licensure survey, conducted 9/15/21 through 9/16/21, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in report.

Based on observation, interview and record review, it was determined the facility failed to ensure required postings were displayed, in a routinely accessible and conspicuous location to residents and visitors and available for inspection. Findings include, but are not limited to:A tour of the facility conducted on 6/16/21 identified the following:* The most recent survey was not posted and available for view;* There was no posting of the facility staffing plan; and* The Ombudsman poster contact information was covered with multiple papers tacked over the poster and not legible.The need to ensure all required postings were in an accessible and conspicuous location for the public was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:During the survey, conducted 6/16/21 through 6/17/21, Oregon Department of Human Services infection control guidelines, which were established to protect the facility staff and residents from the spread of COVID-19 and made available to all facilities, were not being followed by the facility. * The facility had not established adequate storage and disinfection practices for eye protection. Face shields and goggles were observed to be stored without measures in place to prevent contamination; and*Facility staff were observed without face masks in place on both days of the survey. Infection control practices were reviewed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the need for increased oversight of infection control practices in the building.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 6/16/21 at 1:00 pm, the main kitchen was observed to need cleaning in the following areas:*The front surfaces of drawers and cupboards were sticky to the touch;*There were spills, splatters, debris, and crumbs in drawers and cupboards; and*The interior of the cupboards and drawers were not a cleanable surface.The areas needing cleaning and repair were reviewed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure quarterly evaluations were completed and reflective of the residents' current status for 2 of 3 sampled resident (#s 3 and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 7/2020 with diagnoses including renal failure, was insulin dependent, and went to dialysis three times weekly.Resident 3's most recent quarterly evaluation was completed on 4/18/21 and was not reflective of:* The use assistive devices including two different wheelchairs;* Pain issues;* Skin issues, including a shunt for dialysis; and* Specific dietary information.2. Resident 5 was admitted to the facility in 10/2014, with diagnoses including macular degeneration, was receiving hospice services, and required full assistance with all ADLs. Resident 5's most recent quarterly evaluation was completed on 4/1/21 and was not reflective of:* Visual sensory deficit; * Hospice services including bathing assistance;* Meal assistance; and* Pain issues.The need to ensure quarterly evaluations were completed timely, were accurate and included documented changes of condition was discussed with Witness 1 (Consultant). 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' current care needs, provided clear direction for staff, and were followed for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2018, was receiving hospice service, and was identified with a history of falls.An observation of Resident 2's room on 6/16/21 revealed a hospital bed with a mat at bedside.The current service plan failed to be reflective of the resident's current status related to:*Fall injury reduction interventions, including the use of a mat at the bedside; and *Services provided by hospice.2. Resident 3 was admitted to the facility in 2018 with diagnoses including renal failure.Interviews with staff on 6/16/21, and review of the resident's record noted Resident 3 had been hospitalized from June 4 through June 8th 2021 and returned to the facility with a new diagnosis of insulin dependent diabetes. Resident 1's current service plan was not reflective of any interventions or directions to staff for the diagnoses of insulin dependent diabetes. Resident 1 and 2's service plans were discussed with Staff 1 (Interim Administrator). Staff acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provided clear direction for staff for 2 of 3 sampled residents (#s 3 and 5) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 2018 with diagnoses including renal failure and diabetes.An observation of Resident 3's room on 9/15/21 revealed two manual wheelchairs.In interviews with Universal Workers, Resident 3 was identified as going to dialysis three times weekly. Staff reported Resident 3 had a very specific diet and was taken shopping for food preferences by family.The current service plan dated 4/18/21, failed to be reflective of the resident's current status related to:* Wheelchair use; * Specific dietary requirements and preferences; and * Side effects of dialysis.2. Resident 5 was admitted to the facility in 2014 with diagnoses including Macular Degeneration, Alzheimer's dementia, and was receiving hospice services. In interviews with Universal Workers, Resident 5 was identified as requiring full assistance with all care needs including eating. Resident 5 was administered Fentanyl via a patch to manage pain. Resident 5's current service plan, dated 4/1/21, was not reflective of:* Visual impairment and any needed interventions;* Need for full feeding assistance;* Hospice services; and * Pain.Resident 3 and 5's service plans were discussed with Staff 9 (Consultant). Staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed for a resident following a short-term change of condition, document on the progress of the condition at least weekly until resolved, and ensure documentation of interventions were made part of the resident record, for 2 of 2 sampled residents (#s 1 and 3) with changes of condition or who required monitoring. Findings include, but are not limited to:1. Review of Resident 1's record revealed the a facility note on 4/25/21 written by the LPN reported "Resident had a recent dentist appointment after finding one of the resident's bottom teeth missing..."There were no interventions or directions to staff developed or documented related to tooth loss.There was no further documentation or evidence Resident 1 was monitored for the loss of the tooth. 2. Resident 3 was admitted to the facility in 7/2019 with diagnoses of renal failure and was attending dialysis three times a week.On 6/4/21, Resident 3 was admitted to the hospital for uncontrolled vomiting. There was no further documentation or evidence Resident 3's change in condition was monitored following his/her return from the hospital. The need to have a system for responding to changes of condition, including documenting actions and interventions needed for a resident, and monitoring and documenting on the resident's condition until resolved, was discussed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents where monitored per their evaluated need and residents who had short term changes of condition were monitored until resolution for 2 of 2 sampled residents (#s 4 and 5) who experienced changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 4 was admitted to the facility in 2/2021 with diagnoses including Alzheimer's dementia.Resident 4 was observed to wear a cervical collar and utilize a front wheel walker for ambulation. Staff provided stand by assistance with the use of a gait belt.Resident 4 had physician's orders for a dietary supplement four times daily between meals.Resident 4 was observed to independently consume 100% of breakfast and lunch on 9/16/21. Resident 4 was weighed daily with direction to notify the licensed nurse of a two pound change in one day and to reweigh with a three pound change in one week.Resident 4's weights were documented to be:* 8/16/21 - 88 lbs;* 8/24/21 - 99 lbs, a 10 lb, or 11% increase in eight days; and* 9/7/21 - 90 lbs, a 9 lb, or 9% loss in 12 days.Resident 4's weight on 9/16/21 was 92 lbs.There was no documented evidence the significant changes in Resident 4's weight had been evaluated to determine accuracy. There was no documented evidence the RN had been notified of the significant weight changes.The need to monitor residents per their evaluated needs, evaluate changes, and refer significant changes to the RN was reviewed with Witness 1 (Consultant) and Staff 3 (Regional RN). They acknowledged the findings. 2. Resident 5 was admitted to the facility in 2015 with diagnoses including Alzheimer's dementia and was receiving hospice services.Resident 5 was identified to require full assistance with all ADLs.On 8/20/21, Resident 5 was noted to develop a bruise to the nose following a transfer. Interventions were developed and communicated to staff.There was no evidence of monitoring of the bruise until it resolved. The need to ensure short term changes were monitored at least weekly until resolved was reviewed with Witness 1 (Consultant) and Staff 3 (Regional RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status and interventions made as a result of the assessment, for 1 of 1 sampled resident (#3) who experienced a significant decline in condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in 7/2019 with diagnoses of renal failure and was going to dialysis three times a week.An interview with Staff 4 (Assistant Administrator/Universal Worker) on 6/16/21 revealed Resident 3 had been admitted to the hospital and returned with a new diagnosis of Insulin Dependent Diabetes.There was no documented evidence an RN assessment was completed for Resident 3's significant change of condition. The need to complete an RN assessment for significant changes of condition, to include findings, resident status and interventions, was discussed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed for a significant change of condition, including findings, resident status and interventions made as a result of the assessment, for 1 of 1 sampled resident (#4) who experienced significant changes in weight. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 2/2021 with diagnoses including Alzheimer's dementia.Resident 4 was noted to have significant changes in weight between 8/16/21 and 9/7/21.There was no documented evidence the RN had competed and assessment of the significant weight changes.The requirement for RN assessments of significant changes in resident conditions was reviewed with Witness 1 (Consultant) and Staff 3 (Regional RN). They acknowledged the findings.Refer to C 270, example 1.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care was completed in accordance with the Oregon State Board of Nursing (OSBN) Division 47 Rules, for 2 of 2 sampled residents (#1 and 3) who received insulin injections by unlicensed facility staff. Residents 1 and 2 were at risk for harm related to potential medical complications from the lack of an RN assessment of the resident's condition, unlicensed staff training and supervision to ensure safety and accuracy of insulin administration. Findings include, but are not limited to: During the acuity interview on 6/16/21, Resident 1 was identified to be administered insulin injections four times daily by non-licensed staff. Resident 1 received both long and short acting insulin.Resident 3 was identified to be newly diagnosed with insulin dependent diabetes and required insulin injections twice daily by non-licensed staff.1. There was no RN assessment to determine Resident 1's condition remained stable and predictable, or determination of frequency resident should be reassessed, including rationale. Resident 1 had blood sugars tested four times daily. Blood sugars were documented ranging from 71 to 798 between May 1 and June 16 2021. Resident 1 had increases to insulin doses seven times between 2/12/21 and 5/16/21.Resident 1 was administered the incorrect insulin on 2/27/21. The LPN evaluated and monitored the resident and the physician was notified. Staff 4 (Assistant Administrator/Universal Worker) administered Resident 1's insulin 77 times between 5/1/21 and 6/16/21.Staff 5 (Universal Worker) administered Resident 1's insulin 14 times between 5/1/21 and 6/16/21.Staff 6 (Universal Worker) administered Resident 1's insulin 6 times between 5/1/21 and 6/16/21.Staff 7 (Assistant Administrator/Universal Worker of another facility in the corporation) administered Resident 1's insulin 8 times between 5/1/21 and 6/16/21.An agency staff administered Resident 1's insulin 3 times between 5/1/21 and 6/16/21.2. Resident 3 returned from a hospital stay on 6/7/21 with a new diagnosis of insulin dependent diabetes.There was no RN assessment to determine Resident 3's condition remained stable and predictable, or determination of frequency resident should be reassessed, including rationale.Staff 4 (Assistant Administrator/Universal Worker) administered Resident 3's insulin 7 times between 6/7/21 and 6/16/21.Staff 5 (Universal Worker) administered Resident 3's insulin 1 time between 6/7/21 and 6/16/21.Staff 6 (Universal Worker) administered Resident 3's insulin 1 time between 6/7/21 and 6/16/21Staff 7 (Assistant Administrator/Universal Worker of another facility in the corporation) administered Resident 3's insulin 7 times between 6/7/21 and 6/16/21. None of the staff had been delegated by an RN, including:* Rationale why the task could be safely delegated;* Skills, abilities and willingness of Universal Workers to complete the task;* Task was taught to Universal Worker and they were competent to safely perform task;* Written instructions available including risks, side effects, response, risk factors, and whom to report the same;* Universal Workers were taught the task was client specific and not transferable;* Determination of frequency the Universal Worker should be supervised and reevaluated, including rationale; and* RN takes responsibility for delegating task and ensures supervision will occur for as long as RN was supervising performance.There were no licensed staff working in the building. The Regional RN was operating out of a different state. Delegation documentation revealed a former facility LPN had completed facility RN Delegation: Insulin Administration and Client Assessment forms for Resident 1 for Staff 4 and Staff 6, operating out of her scope of practice. The forms were not signed by the staff.On 6/16/21, the need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the above findings. The Surveyor requested an immediate plan to ensure insulin was administered by licensed or delegated staff in accordance with OSBN Division 47 Rules.On 6/16/21 at 4:30 pm, a plan to address the delegation issue was submitted and the situation was abated.
Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules, for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed staff. This is a repeat citation. Findings include, but are not limited to:1. Delegation records for Resident 3, reviewed with Staff 3 (RN) on 9/16/21, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 4 (House Manager/MT), Staff 5 (Universal Worker/MT), and Staff 6 (Universal Worker/MT) to include:* Frequency the client should be reassessed, including rationale; and* Frequency the CG should be supervised and reevaluated, including rationale.The RN failed to document all required components of delegation for Staff 4 including:* Skills, abilities and willingness of CG;* Task was taught to CG and they are competent to safely perform task; and* CG taught task was client specific and not transferable.2. Staff 4 (House Manager/MT), Staff 5 (Universal Worker/MT), and Staff 6 (Universal Worker/MT were initially delegated to perform insulin injections for Resident 3 on 6/17/21. Re-evaluation of the staff's delegation duties were not completed within 60 days of initial delegation.Staff 3 (Regional RN) immediately addressed the delegation issues. The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 3 (Regional RN) and Witness 1 (Consultant) on 9/16/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:1. Administrative oversight of the medication and treatment administration system was found to be ineffective, based on deficiencies in C 282: Delegation.The lack of adequate professional oversight was discussed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). The staff acknowledged the findings.2. Refer to C 303 and C 310.

Based on observation, interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 3 of 3 sampled residents (#s 1, 2 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 1 had diagnoses which included renal failure.Resident 1 had physician's orders for:*Chantix 1 mg daily for smoking cessation; and*Weekly weights with directions to re-weigh with three pound or more difference.May 1 through June 16 2021 MARs revealed the Chantix was not given as ordered and Resident 1 was not re-weighed as directed when weight varied by three pounds or more.Resident 1's June 1 through June 16 2021 MARs revealed Resident 1 was administered the following medications without signed prescriber orders:*Aspirin 81 mg daily;*Aveidaoxia 1% applied topically twice daily; and*Memantine titrated up from 0.5 mg daily to 10 mg twice daily.2. Resident 2 had diagnoses including dementia.Resident 2 had physician's orders for:*Hi Cal Supplement 8 oz twice daily; and*Weekly weights with directions to re-weigh with three pound or more difference.May 1 through June 16 2021 MARs revealed the supplement was not given as ordered and Resident 2 was not re-weighed as directed when weight varied by three pounds or more.3. Resident 3 had diagnoses including renal failure and high blood pressure.Resident 3 had physician's orders for:*Losartan Potassium 25 mg for blood pressure daily;*Renvela 800 mg for renal failure three times daily with the first bite of each meal;May 1 through June 16 2021 MARs revealed the Losartan Potassium and the Renvela were not given as ordered.The need to ensure signed physicians' orders were in residents charts and followed was reviewed with Staff 1 (Interim Administrator) She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 3 sampled residents (#3) whose orders were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 7/2020 and had diagnoses including insulin dependent diabetes.Resident 3 had physician's orders for Glucose Oral tablet 4 mg, four tablets to be chewed if blood sugars were below 60.On 8/16/21, Resident 3's blood sugar was recorded as 55 at 5:20 am.There was no evidence the Glucose Oral tablets had been administered to treat the low blood sugar. There was no documented re-check of Resident 3's blood sugar. The need to ensure physician's orders were carried out as prescribed was reviewed with Staff 3 (Regional RN) and Witness 1 (Consultant). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#3) whose MARs included multiple PRN medications used to treat the same condition. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2019 with diagnoses which included renal failure.Residents 3's physician's orders and 5/1/21 through 6/16/21 MARs were reviewed.Resident 3 had orders for:*Metocloramide 5 mg as needed for nausea/vomiting; and*Ondansetron HCI 8 mg as needed for nausea/vomiting.There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure resident MARs included resident specific parameters and instructions for PRN medications, for 1 of 3 sampled residents (#4) whose MARs included multiple PRN medications used to treat the same condition. This is a repeat citation. Findings include, but are not limited to:Resident 4 was admitted to the facility in 2/2021 with diagnoses including Alzheimer's dementia and had a recent hip fracture.Residents 4's physician's orders and 8/1/21 through 9/15/21 MARs were reviewed.Resident 4 had orders for:*Tylenol Extra Strength 500 mg as needed for pain; and*Oxycodone HCI 5 mg as needed for pain.Resident 4 was administered both medications multiple times between 8/1/21 and 9/15/21. There were no resident specific parameters and instructions for which PRN medication to use first. The need to ensure there were clear parameters for unlicensed staff when administering multiple PRN medications for the same condition was discussed with Staff 3 (Regional RN) and Witness 1 (Consultant). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a qualified administrator was employed to work 40 hours per week. Findings include, but are not limited to:On 9/15/21, the surveyor entered the facility at 1:00 pm. Staff 4 (House Manager/Universal Worker) reported she was the new Administrator.Staff 4 worked in the facility as a Universal Worker and was observed to administer medications, provide resident care, cook and serve meals, and complete housekeeping. The need to have a qualified administrator employed to work 40 hours per week was discussed with Witness 1 (Consultant). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training, was completed prior to providing services to residents for 2 of 2 newly hired staff (#s 4 and 5) whose training records were reviewed. Findings include, but are not limited to:Staff training records were requested on 6/16/21.Staff 4 (Assistant Administrator/Universal Worker), hired 7/6/20 and Staff 5 (Universal Worker), hired 1/27/20, lacked documented evidence of having completed pre-service dementia training.The need for staff to complete required pre-service dementia training before working with residents was reviewed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired caregiving staff (#s 4 and 5) demonstrated satisfactory performance in all job duties and were certified in First Aid and trained in abdominal thrust within 30 days of hire. Findings include, but are not limited to:Training records were requested on 6/16/21.There was no documented evidence Staff 4 (Assistant Administrator/Universal Worker), hired 7/6/20, and Staff 5 (Universal Worker), hired 1/27/20 had demonstrated competency in all required areas and within 30 days of hire including:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment and observation and reporting.2. There was no documented evidence Staff 4 and Staff 5 had completed First Aid certification and abdominal thrust training within 30 days of hire.The need to ensure it was documented staff had demonstrated competence in all job duties within 30 days and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Interim Administrator) and Staff 2 (Vice President of Operations). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 1 of 1 long-term staff (#6) whose training records were reviewed. Findings include, but are not limited to:The annual in-service training records for the Year 2020 were reviewed on 6/16/21 and revealed the following:* Staff 6 (Universal Worker), hired 2/13/2019, failed to have documented evidence of completing 12 hours of required in-service training. Staff 1 (Interim Administrator) acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:On 6/16/21, fire drill and fire and life safety training records for the previous six months were requested.Review of the documentation provided identified the following: * There was no documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, evening and night shifts; and * There was no documented evidence fire and life safety instruction to staff was provided on alternate months. The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to instruct residents within 24 hours of admission, and re-instruct residents 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, failed to ensure a written record of fire safety training, including content of the training sessions and the residents attending, was kept, and failed to document alternating exit routes during fire drills. Findings include, but are not limited to:There was no documented evidence residents had been instructed on fire and life safety procedures upon admission and re-instruction at least annually, including a written record of fire safety training, with content of the training sessions and the residents attending. Review of available fire drill records revealed no evidence of alternating exit routes.The need to ensure residents received fire and life safety training within 24 hours of admission and re-instruction at least annually, and kept a written record of the training, including content and the residents attending, was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:Refer to C150, C260, C270, C280, C282, C303 and C310.

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not contain drop offs and that walkways were maintained in good shape to prevent tripping hazards for residents. Findings include, but are not limited to:Observations of the exterior of the facility on 6/16/21 showed drop offs at the pathway edges in excess of three inches in multiple areas. Additionally, there was a damaged area in the cement pathway near the door with uneven surfaces and chunks of concrete missing. The need to ensure pathways in the resident courtyard did not have potential tripping hazards was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to provide lever type door handles on all doors utilized by residents. Findings include, but are not limited to:Observation of the facility on 6/16/21 revealed the closet door of resident Room 2 had a door knob, not a lever type handle. The findings were reviewed with Staff 1 (Interim Administrator) who acknowledged the finding.

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 on 6/16/21 showed that all exit doors did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance). They acknowledged the findings.