Marquis Tualatin Assisted Living

The findings of the re-licensure survey conducted 04/11/23 through 04/14/23 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 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 first re-visit to the re-licensure survey of 04/14/23, conducted 07/20/23, 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 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 04/14/23, conducted 10/09/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

Based on interview and record review, it was determined the facility failed to immediately investigate an injury of unknown cause and document that it reasonably concluded the injury was not the result of abuse, or report the injury to the local SPD office, for 1 of 1 sampled resident (#2) with an injury of unknown cause. Findings include, but are not limited to:Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.Review of Resident 2's clinical records during the survey noted the following:* 02/20/23 - "Skin tear observed on right arm...HH Certified Nurse Aide reported she found it when providing shower for [resident]." The facility lacked an investigation into the injury of unknown cause which reasonably concluded and documented the injury was not the result of abuse. The injury was not reported to the local SPD office.The need to immediately investigate injuries of unknown cause to reasonably rule out abuse and neglect or report the injury to the local SPD office was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings. The survey team requested the facility submit the report. Documentation was provided prior to survey exit.

Based on observation, interview and record review, it was determined the facility failed to consistently determine, document and communicate to staff what actions or interventions were needed for a resident following a change of condition, ensure the determined actions were made part of the resident's record, note progress of the condition until resolved and monitor the resident consistent with his or her evaluated needs and service plan for 5 of 6 sampled residents (#s 1, 2, 3, 4 and 6) who experienced changes of condition which required monitoring. Findings include, but are not limited to:1. The sampled residents' records were reviewed for changes of condition. In response to some change of condition events, staff documented in a progress note that the resident was placed on "alert." There was then documentation by staff that the resident's condition was monitored and, at some point, the monitoring was discontinued by the facility RN with a note indicating the resident's condition had returned to baseline or had resolved. However, there were no documented instructions for staff in the resident's record indicating what actions or interventions had been put in place following the change of condition.In an interview on 04/13/23, Staff 2 (RN) explained that when a resident was placed on alert charting, instructions for staff were documented in the facility's electronic records system. She acknowledged, however, that when the alert was discontinued, the electronic system did not retain a record of the actions or interventions the facility had initially developed for the resident in response to the change of condition. She further acknowledged that if no monitoring was documented in the progress notes, it indicated the facility failed to place the resident on alert charting, i.e. the facility failed to determine, document and communicate to staff what actions or interventions were needed for the resident in response to the change of condition. She acknowledged this system did not meet the rule requirements.The need to ensure the facility had a system to make staff instructions or interventions part of the resident's record following a change of condition was reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the deficiencies with the facility electronic record system.2. Resident 1 was admitted to the facility in 08/2014 with diagnoses including Alzheimer's disease, cerebellar stroke syndrome and cerebral infarction.Review of the record indicated Resident 1 experienced the following changes of condition which required monitoring:* 02/13/23 - Scratched self on left arm causing bleeding;* 02/21/23 - Due to itchiness, scratched face resulting in a "gash" that was bleeding; and* 02/23/23 - Was found by staff outside in the parking lot, confused and looking for his/her car to go home.There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident or monitored and documented on the resident at least weekly until the conditions were determined to be resolved. The facility failed to monitor Resident 1's service plan to determine if information regarding his/her risk for leaving the building unsupervised was accurate or whether additional interventions needed to be developed to ensure the resident's safety.The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23 and 04/13/23, respectively. They acknowledged the findings.3. Resident 4 was admitted to the facility in 08/2015 with diagnoses including late onset Alzheimer's disease, adjustment disorder and atrial fibrillation.Review of the record indicated Resident 4 experienced the following changes of condition which required monitoring:* 02/10/23 - Non-injury fall in the resident's room;* 03/13/23 - Non-injury fall while walking to his/her room from the dining room;* 03/15/23 - Fall resulting in injuries to left biceps and right elbow area;* 03/18/23 - Was found by staff outside in the parking lot, confused and looking for his/her spouse; and* 04/05/23 - Minor skin wound across top of left ankle from refusing to allow staff to remove his/her compression stockings at bedtime.There was no documented evidence the facility determined, documented and communicated to staff what actions or interventions were needed for the resident or monitored and documented on the resident at least weekly until the conditions were determined to be resolved. The facility failed to monitor Resident 4's service plan to determine if information regarding his/her risk for leaving the building unsupervised was accurate and instructions for staff regarding what to do if the resident refused to allow compression stockings to be removed were adequate, or whether additional interventions needed to be developed to ensure the resident's health and safety.The need to ensure the facility determined, documented and communicated to staff what actions were needed in response to a resident's change of condition, and that the resident was monitored with weekly progress noted until the condition resolved, was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23 and 04/13/23, respectively. They acknowledged the findings.
6. Resident 2 was admitted to the facility in 12/2021 with diagnoses including dementia.The resident's 01/11/23 through 04/11/23 progress notes were reviewed and revealed the following:* 03/28/23 - "Patient eye is red and had a lot of gooey green [discharge] in it;" and * 01/18/23 - "...Resident had a quite a bit of green [discharge] coming out of [his/her] left eye."In an interview on 04/14/23, Staff 2 (RN) stated the facility contacted the resident's primary physician regarding the eye condition on 04/11/23, 15 days after it was discovered. Staff 2 confirmed the facility failed to monitor the resident's condition noting any progress at least weekly. The lack of monitoring of Resident 2's change of condition was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.
4. Resident 3 was admitted to the facility in 11/2021 with diagnoses including hypoxemia and personal history of venous thrombosis and embolism.Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 04/04/23, and progress notes dated 02/02/23 through 04/09/23 were reviewed.a. The following short-term change of condition lacked documentation of progress, at least weekly, through resolution:* 03/01/23 - Emergency department visit for kidney stones.b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution:* 02/07/23 - Rash on right side of groin;* 02/08/23 - Increased confusion;* 02/10/23 - Left leg pain;* 02/20/23 - Pain in left arm and shoulder; * 02/22/23 - Pain in the right big toe; and* 03/28/23 - New finasteride prescription. The need to ensure short-term changes of condition had actions or interventions documented in the resident record, the determined actions or interventions were communicated to staff on all shifts and progress was noted, at least weekly, until resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings.5. Resident 6 was admitted to the facility in 06/2022 with diagnoses including multiple sclerosis. Observations of and interviews with the resident, interviews with staff, review of the resident's service plan dated 02/24/23, progress notes dated 01/13/23 through 04/11/23 and fall investigation reports were reviewed.a. The following short-term changes of condition lacked documentation of progress, at least weekly, through resolution:* 02/26/23 - Fall.b. The following short-term changes of condition lacked documentation of the actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly and documentation of resolution:* 02/07/23 - Death of resident's best friend;* 02/12/23 - Missed all evening medications;* 02/20/23 - New trazadone prescription and change in duloxetine dosage;* 03/10/23 - Decrease in trazadone;* 04/05/23 - Skin tear from fall;* 04/05/23 - Nosebleed; and* 04/07/23 - New tamsulosin prescription.The need to ensure short-term changes of condition had actions or interventions documented in the resident record, the determined actions or interventions were communicated to staff on all shifts and progress was noted, at least weekly, until resolution was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to determine and document what actions or interventions were needed, communicate the interventions or actions to staff with weekly progress noted through resolution for 2 of 2 sampled residents (#s 7 and 8) who experienced short term changes of condition. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 moved into the facility in 01/2022 with diagnoses including aphasia and hypertension.The resident's clinical record, including progress notes, and incident reports, were reviewed and interviews were conducted. The following change of condition was identified:On 06/27/23 a fall was noted in the progress notes. The following information was identified:*06/30/23 - "Resident is presenting with pain since [his/her] fall. Resident has remained in apartment all shifts, and opted into getting [his/her] dinner delivered to [his/her] room. Resident is still protecting [his/her] arm."Review of the available facility records revealed there was no documented evidence the facility, determined and documented actions or interventions were needed with instruction to staff nor was there evidence the resident had been monitored at least weekly through resolution. Resident 8's change of condition was discussed with Staff 1 (Administrator) on 07/20/23. She acknowledged the findings.

2. Resident 7 was admitted to the facility in 04/2017 with diagnoses including kidney failure and a total hip replacement.Review of the record from 06/13/23 to 07/20/23 identified the following short term change of condition.A progress note dated 07/04/23 documented that "medtech went to the resident saw caregiver talking to resident about a skin tear on his left knee. When asked if it hurts, he replied no. The area of the skin discolored bruise". There was no documented evidence the facility determined what action or intervention was required for the resident, communicated actions or interventions to staff and there was no evidence of weekly monitoring through resolution. Resident 7's change of condition was discussed with Staff 1(Administrator) on 07/20/23. She acknowledged the findings.
1. Resident # 8's fall intervention Service Plan has been updated and short-term change of condition has resolved. Resident # 7's skin tear has resolved without complications.2. Resident Services Coordinator will be re-inserviced on Temporary Service Plans and will complete a daily audit of all new alerts from the previous working day and open temporary service plans. Med Techs, Caregivers & RSC will be re-inserviced on Alert Charting policy and procedures, including skin tears. 3. Facility RN or designee will review documentation and remove from alert when resolved.4. Residents placed on alert charting will be reviewed daily (M-F) during stand-up process and will be audited weekly for four weeks and quarterly thereafter by the facility Admin, RN or designee to ensure alert charting and temporary service plan is in place per policy. 5. Facility RN is responsible for ensuring monitoring and compliance.

2. On 04/14/23 at 11:20 am, a medication cart was observed in the first floor hallway outside the staff work area. The cart appeared to be unlocked and no staff were present. Upon inspection, the cart was unlocked and contained resident prescription medications and wound care supplies. At approximately 11:22 am, Staff 2 (RN) came out of a nearby office. The surveyor informed her of the unlocked medication cart - she immediately locked it.The need to ensure medications were stored in locked containers in a secure environment was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure all medications administered by the facility were stored in locked containers in a secure environment such as a medication room or medication cart. Findings include, but are not limited to:1. On 04/13/23 at 8:36 am, a medication cart was observed to be unlocked and located in an open and unlocked medication room on the first floor. Further inspection by this surveyor confirmed the medication cart held prescription medications for residents in the facility. At approximately 8:41 am Staff 2 (RN) and Staff 6 (CG) returned to the medication room. This surveyor informed both staff members the medication cart was unlocked and left in an unlocked and open medication room with no staff present. Staff 2 immediately shut and locked the door of the medication room.The need to ensure medications were stored in locked containers in a secure environment was discussed with Staff 2 on 04/13/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications, for 1 of 1 sampled resident (#1) who was prescribed a PRN psychotropic medication requiring non-drug interventions be attempted prior to administration. Findings include, but are not limited to:Resident 1 was admitted to the facility in 08/2014 with diagnoses including Alzheimer's disease, cerebellar stroke syndrome and cerebral infarction.Review of the record indicated Resident 1 was prescribed lorazepam intensol (to treat anxiety or agitation) 2mg/ml, administer 0.25 ml (0.5 mg) by mouth or sublingually as needed every 2 hours. The orders noted Resident 1 was on hospice and staff should call the RN or hospice before administering.The MAR, reviewed between 04/01/23 and 04/10/23, indicated staff administered the lorazepam PRN on 04/07/23 and 04/08/23. There was no documented evidence the staff attempted non-drug interventions with ineffective results or contacted the RN or hospice prior to administering the medication.The need to ensure there were non-pharmacological interventions to attempt, documentation that the interventions were attempted and ineffective and documentation the RN or hospice were contacted prior to administering Resident 1's PRN psychotropic medication was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 04/14/23. They acknowledged the findings and Staff 2 stated the facility had to develop a method for documenting non-pharmacological interventions on the electronic MAR.

Based on interview and record review, it was determined the facility failed to update the Acuity-Based Staffing Tool (ABST) following a significant change of condition and no less than quarterly, for 3 of 6 sampled residents (#s 1, 3 and 4). Findings include, but are not limited to:The facility used the Oregon Department of Human Services ABST. Review of the data for Residents 1, 3 and 4 indicated the ABST for each resident had not been updated since their records were originally created on 06/01/22. Residents 1 and 4 had experienced significant changes of condition on 01/18/23 and 03/14/23, respectively.The need to ensure ABST records were updated no less than quarterly and following a significant change of condition was reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired direct care staff (#s 8, 9 and 10) completed pre-service orientation and pre-service dementia training before providing care and services to residents and failed to ensure 2 of 2 long term staff (#s 1 and 14) completed training addressing infectious disease prevention by 07/01/22. Findings include but are not limited to: a. Staff training records were reviewed with Staff 1 (Administrator) on 04/13/23 and identified the following:Staff 8 (CG), hired on 01/21/23, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents:* Resident rights and values of community based care; and* Infectious disease prevention.Staff 9 (CG), hired on 01/09/23, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents:* Resident rights and values of community based care;* Abuse reporting requirements; and* Infectious disease prevention.Staff 10 (MA), hired on 12/29/22, lacked documented evidence pre-service orientation training was completed in the following areas before providing care to residents: * Resident rights and values of community based care;* Infectious disease prevention; and* Fire safety and emergency procedures.b. Staff 8, 9 and 10 lacked documentation the following pre-service dementia training was completed prior to providing care to residents:* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;* Techniques for understanding, communicating and responding to behaviors reducing use of antipsychotics;* Strategies for addressing social needs and engaging them in meaningful activities; and* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering and use of person-centered care. c. Staff 1, hired 05/14/07, and Staff 14 (Cook), hired 03/03/21, lacked documentation infectious disease prevention training was completed prior to 07/01/22. The need to ensure newly hired direct care staff completed pre-service orientation and pre-service dementia training before providing care to residents and long term staff completed infectious disease prevention training prior to 07/01/22 was discussed with Staff 1 on 04/13/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 8, 9 and 10) demonstrated competencies in all required training within 30 days of hire. Findings include, but are not limited to:Staff training records were reviewed on 04/13/23. Staff 8 (CG), hired on 01/21/23, and Staff 9 (CG), hired on 01/09/23, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:* Role of service plans in providing individualized care;* Providing assistance with ADLs;* Changes associated with normal 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 and abdominal thrust training.Staff 10 (MA), hired on 12/29/22, failed to have documented evidence of competency demonstrated in all assigned job duties prior to working independently with residents in the following areas:* Providing assistance with ADL's;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; and* General food safety, serving and sanitation.The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working independently with residents was reviewed with Staff 1 (Administrator) on 04/13/23. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure 1 of 1 sampled newly-hired direct care staff (#17) demonstrated competencies in assigned job tasks before working unsupervised. This is a repeat citation. Findings include:Records of training for staff hired after 06/13/23 were reviewed on 07/20/23.Training records for Staff 17 (Med Aide), hired on 06/27/23, failed to show that appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments), had observed and evaluated the individual's ability to perform safe medication and treatment administration independently before administering medications unsupervised.The need to ensure newly hired direct care staff had documented evidence of demonstrated competency in all assigned job duties prior to working unsupervised with residents was reviewed with Staff 1 (Administrator) on 07/20/23. She acknowledged the findings and stated the staff would demonstrate competency before administering medications.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long term staff (#s 11, 12 and 13) whose training records were reviewed. Findings include, but are not limited to:Annual in-service training records were reviewed with Staff 1 (Administrator) on 04/13/23. Staff 11 (MA), hired on 01/05/17, Staff 12 (CG), hired on 06/12/19 and Staff 13 (CG), hired on 02/06/17, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on their hire dates, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, and at least six hours of dementia care training, The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 on 04/14/23. She 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:Fire drill and fire and life safety training records from 10/11/22 to 04/11/23 were reviewed with Staff 3 (Maintenance Director) on 04/13/23. The following deficiencies were identified:1. The facility failed to show documented evidence fire drills were conducted every other month. Fire drills conducted and recorded on 02/08/23 and 04/04/23 lacked the following information:* Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated.2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually. Findings include, but are not limited to:Fire and life safety records were reviewed with Staff 3 (Maintenance Director) on 04/13/23.There was no documented evidence residents were instructed within 24 hours of admission and re-instructed at least annually in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside of the building or within the fire safe area in the event of an actual fire.The need to ensure residents received fire and life safety training within 24 hours of admission and were re-instructed at least annually was discussed with Staff 1 (Administrator) on 04/14/23. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure residents were instructed within 24 hours of admission in fire and life safety procedures as required by the Oregon Fire Code (OFC). This is a repeat citation. Findings include, but are not limited to:Fire and life safety records were reviewed on 07/20/23, Staff 1 (Administrator) was interviewed, and the following were identified: There was no documented evidence residents were instructed within 24 hours of admission on general fire and life safety procedures, evacuation methods, responsibilities, and designated meeting places inside or outside the building in the event of an actual fire. On 07/20/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission as required by the OFC was discussed with Staff 1. The findings were acknowledged.
1. All current residents will receive education on facility fire safety procedures, evacuation methods, and responsibilities during fire drills. Upon reciept of education, each resident will sign an acknowledgement form. 2. Fire and Life Safety training will be provided to all new residents within 24-hours of admission and reviewed annually thereafter. Documentation supporting this training will be maintained.3. Administrator or designee will audit every week for 4 weeks and then quarterly thereafter to ensure compliance.4. Maintenance Director is repsonsible for monitoring and ensuring compliance

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 C 270, C 372 and C 422.

Based on observation and interview, it was determined the facility failed to ensure covers, grates or screens of wall heaters did not exceed 120 degrees Fahrenheit when they were installed in locations that were subject to incidental contact by residents or with combustible material. Findings include, but are not limited to:During an environmental walk-through on 04/12/23, the metal surface on the wall heaters located in apartments with one or two bedrooms exceeded 120 degrees F when turned on. On 04/12/23, Staff 3 (Maintenance Director) observed the surveyor test the wall heater in room 360, acknowledged it measured approximately 220 F, and confirmed that all of the cadet wall heaters in the one bedroom and two bedroom units were the same style, and all exceeded 120 F.The need to ensure residents could not come into incidental contact with wall heaters that exceeded 120 degrees F was discussed with Staff 1 (Administrator). She acknowledged the findings and the wall heaters were disabled prior to survey exit on 04/14/23.