The findings of the Change of Ownership survey, conducted 04/25/22 through 04/26/22, 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.

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 revisit to the re-licensure survey of 04/26/22, conducted 08/01/22 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities.

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

Resident 4 was admitted to the facility in 03/2022 with diagnoses including diabetes.

Review of Resident 4's new move-in evaluations, dated 02/10/22 and 02/28/22 revealed the evaluation lacked the following elements:

* Memory, orientation and decision making abilities;

* Transportation;

* Indicators of nursing needs including potential for delegated tasks;

* History of dehydration or unexplained weight loss or gain; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature.

The need to ensure all required elements were included in the new move-in evaluation was discussed with Staff 1 (ED), Staff 2 (VP of Clinical Operations/RN) and Staff 4 (LPN) on 04/26/22. They acknowledged the findings.

1.  Trained our RCCs who do the evaluations on what reqiured elements are needed in the move in evaluation.  Given them a list (taken directely from the CBC forms on line so they can refer to them for reference as well as the OAR.    

2. We  have updated our move in evaluation to reflect all of the required elements.

3. This will be reviewed with each new move in.

4. The Administrator will be responsible for this ensuring the corrections are completed/monitored. .

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

During the acuity interview on 04/25/22, Resident 4 was identified to be administered insulin injections by non-licensed staff.

Initial delegation records for Staff 9, 11 and 16 (MTs), reviewed on 04/26/22, lacked documentation in the following areas:

* An RN assessment of the resident's condition;

* How frequently the client should be reassessed by the RN, including rationale; and

* That the RN took responsibility for delegating tasks and ensured supervision would occur for as long as the RN was supervising performance.

Periodic inspection, supervision and reevaluation of delegation records were reviewed for Staff 9 (MT), and lacked documentation in the following area:

* An RN assessment of the resident's condition to determine that the diabetic condition remained stable and predictable.

The need to ensure all staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 1 (ED) and Staff 2 (VP of Clinical Operations/RN) on 04/26/22. They acknowledged the findings.

1.  Reviewed with the RN what is required with each delegation.  All current delegations updated to new forms.

2.  Updated Delegation forms to reflect all required information.

3. This will be evaluated with each new delegation.

4. RN, Regional Nurse and Administrator will be responsible for ensuring the correctionsa are completed/monitored.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months from fire drills. Findings include, but are not limited to:

Fire and life safety records, reviewed for the months between 08/2021 and 03/2022, revealed that fire and life safety instructions were not provided to staff on alternating months from the fire drills.

In an interview on 04/25/22, Staff 7 (Maintenance Director) reported the facility had not been providing fire and life safety instructions to staff except for when fire drills were completed.

The need to ensure fire and life safety instructions were provided to staff on alternate months from fire drills was discussed with Staff 1 (ED) and Staff 2 (VP of Clinical Operations/RN) on 04/25/22.  They acknowledged the findings.

1.  A fire and life safety training was done in April.

2.  A calander will be impleted to show which months are fire drills (and what shift) and which months are fire and life safety training (with the topic).

3. This will be evaluated quarterly to ensure the proper training is being completed.

4. The Maintenance Director and Administrator will be responsbile for enusring the corrections are completed/monitored.

Based on observation and interview, it was determined the facility failed to ensure the electric fireplace did not exceed 120 degrees Fahrenheit (F) in a location that was subject to incidental contact by residents. Findings include, but are not limited to:

A tour of the facility on 04/25/22 revealed the following:

An electric fireplace located on the second floor of the facility was turned on by the surveyor. The cover of the heating element of the fireplace reached a temperature above 120 degrees F.

The need to ensure the cover of the electric fireplace did not reach above 120 degrees F was discussed with Staff 1 (ED), and Staff 8 (Director of Operations). They acknowledged the findings.

On 04/25/22, Staff 1 notified the surveyor the electric fireplace had been disabled. They surveyor confirmed the electric fireplace was disabled on 04/25/22 at 3:10 pm.

1. The fire place was immediately turned off at the electric panel when this was brought to our attention.

2. A sign has been placed by the electrical panel to not turn them on again.  Maintenace has added the task to his monthly routine items to check that it is still turned off at the electric planel.

3. Monthly.

4. The Maintenance Director and Administrator will ensure that the corrections are completed and monitored.