The findings of the re-licensure survey, conducted 8/9/21 through 8/10/21 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.
Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.
Abbreviations possibly used in this document:
ADL:activities of daily living
bid:twice a day
CBG:capillary blood glucose or
blood sugar
CG:caregiver
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
LPN:Licensed Practical Nurse
MA: Medication Aide
MAR:Medication Administration
Record
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 first re-visit to the re-licensure survey of 08/10/21, conducted 11/29/21 through 11/30/21, 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, 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 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 08/10/21, conducted 02/03/22, are documented in this report. It was determined the facility was in substantial 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 for Home and Community Based Regulations.
2. Resident 1 was admitted to the facility in August 2020 with diagnoses including dementia.
Review of incident reports and progress notes from 7/15/21 to 7/31/21 showed the following:
* An incident report dated 7/15/21 was created after Resident 1 sustained a skin tear to the left hand. The report indicated the resident was unable to recall how s/he had gotten the skin tear.
There was no investigation completed related to this incident to rule out abuse and neglect and it was not reported to the local SPD office.
The need to ensure resident incidents were promptly investigated to rule out abuse and neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director) and Staff 3 (RN) on 8/10/21. The staff acknowledged the findings.
The facility was asked to report the incident from 7/15/21 to their local SPD office and a confirmation was provided prior to exit.
Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 3 of 3 sampled residents (#1, 2 and 3) who were reviewed with injuries from falls or unknown cause. Findings include, but are not limited to:
1. Resident 2 moved into the facility in October of 2020 with a diagnosis dementia.
Review of Resident 2's record revealed s/he sustained an injury on 6/15/21 after s/he hit his/her head on the floor as s/he fell out of a recliner sustaining a rug burn on their nose. Resident 2 appeared confused after the fall and an ambulance was called to take him/her to the ER.
Interview with Staff 1 (Administrator) on 10/10/21, about the incident on 6/15/21, determined the facility failed to report the injury fall to the local SPD office. The surveyor asked Staff 1 to report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 8/10/21.
The need to ensure resident incidents were thoroughly investigated and reported to the local SPD office was discussed with Staff 1 and Staff 2 (Regional Director) on 8/10/21. They acknowledged the findings.
3. Resident 3 was admitted to facility 12/2020 with a diagnosis including dementia.
Resident 3's current service plan noted the resident was at risk for falls.
Review of Resident 3's record noted multiple unwitnessed falls between 2/23/21 and 8/3/21. There was no documented evidence how the facility determined the fall was not the result of neglect or abuse.
The need to thoroughly investigate all incidents to rule out suspected abuse and/or neglect was discussed with Staff 1 (Administrator), Staff 2 (Regional Director), Staff 3 (RN) and Staff 4 (RCC) on 8/10/21. They acknowledged the findings.
1. Action taken to correct this rule/violation is that Management RN/LPN/RCC and, or Administrator will conduct complete and full investigations of abuse, suspected abuse, or injuries of an unknown causes on all incidents discovered from the prior day.
2. How this system will be corrected so this violation will not happen again. We will review Incident Reports Monday through Friday during our clinical meeting.
3. This area needing correction will be reviewed daily Monday through Friday.
4. The Resident Care Coordinator will be responsible to ensure that Incident Reports are reviewed with Administrator, and/or RN each morning to determine if the incident needs to be reported to Adult and Protective Services. Administrator will conduct the final investigation, and report any incidents of abuse, suspected abuse, or injuries of unknown cause the proper authorities within 24 hours of each incident.
Based on observation, interview and record review, it was determined the facility failed to notify RN of a change in condition, document and communicate resident specific interventions, evaluate, and monitor weekly until resolution for 1 of 1 sampled resident (#2) who experienced a severe weight gain. Findings include, but are not limited to:
Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia.
Resident 2's weight record, progress notes and interim service plans were reviewed on 8/9/21 and revealed the following:
Residents 2's weight was noted to be 102.8 pounds on 2/24/21.
Resident 2's weight on 5/26/21 was documented to be 120.8 pounds.
This constituted a 16 pound, or 13.2%, severe weight gain in three months.
Review of progress notes and interim service plans determined there was no documented evidence the facility evaluated and monitored the change of condition or implemented interventions related to the severe weight gain.
Interview with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21 revealed there was no RN assessment or monitoring completed for Resident 2's weight gain or notification from staff that Resident 2 had a change of condition.
Observation on 8/9/21 and 8/10/21 showed Resident 2 ate 100% during meals. Review of Resident 2's meal record showed s/he consistently ate 100% of all meals.
The need to ensure staff notified the RN of a change of condition, documented and communicated resident specific interventions, evaluated, and monitored weekly until resolution was discussed with Staff 1 (Administrator) on 8/12/21. She acknowledged the findings.
1. The action taken is the clinical team will review residents whom are identified as high risk for a Change of Condition including temporary, and Significant on a weekly basis. The RN/RCC will review weights weekly during the clinical meetings, and identify who needs to be more closely monitored.
2. How this system will be corrected is once a resident has been identified a temporary, or significant change of condition will be intiated by the RN, and the staff will be provided new care instructions via a revised Growth & Wellness Plan.
3. The area needing correction: these will be evaluated weekly, by the Administrator.
4. The Administrator and RN will be responsible to see that the corrections are completed/monitored.
Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#2) who experienced significant changes of condition related to a weight change. Findings include, but are not limited to:
Resident 2 was admitted to the facility in October of 2020 with a diagnosis of dementia.
Residents 2's weight was noted to be 102.8 pounds on 2/24/21.
Resident 2's weight on 5/26/21 was documented to be 120.8 pounds.
This constituted a 16 pound, or 13.2%, severe weight gain in three months.
There was no documented evidence the RN completed a Change of Condition assessment which included findings, resident status, and interventions made as a result of the 16 pound weight gain.
The need to ensure an RN assessment was completed for residents who experience a significant changes of condition was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 8/10/21. They acknowledged the findings.
1. Action to correct this violation is to monitor each resident closely, and identify changes mentally or physically, in a timely manner, and to monitor the changes.
2. The system will be corrected during our daily clinical meeting. The clinical team will identify residents who need to be monitored closer via our Electronic Medical Record System, and observation notes per the Medication Aides.
3. The RN, and RCC will monitor this system weekly to ensure the necessary monitoring of residents is complete.
4. The RN will be responsible for weekly notes and instructing the care staff, as needed, of any changes in regards to the residents.
Based on interview and record review, it was determined the facility failed to ensure all requirements were met for Fire and Life Safety preparedness, instruction and documentation. Findings include, but are not limited to:
Fire and life safety training and records were reviewed with Staff 6 (Maintenance Director) on 8/10/21 at 10:10 am. The following was identified:
* No documented evidence the facility was providing fire and life safety instruction to staff on alternating months from fire drills;
* No documented evidence fire drills were conducted every other month;
* No documentation of escape route used;
* No documentation of problems encountered and comments relating to residents who resisted or failed to participate in the drills; and
*No documented evidence of alternate routes being used during fire drills.
On 8/10/21, the above areas were reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.
1. Actions to correct this violation is to conduct and record Fire & Life Safety Drills, and provide instructions as per OAR 411-054-0090.
2. This system will be corrected as the Maintenance Director will conduct announced and unannounced Fire & Life Saftey Drills on a monthly basis during mandatory staff meetings. The unannounced Fire Drills will be conducted every other month and all in-service trainings will be appropriately documented, including alternate routes used during fire drills.
3. This area needing correction will be monitored by the Administrator on a monthly basis.
4.The Maintenance Director will be responsible to see that these corrections are completed/monitored utilizing the TELS system.
Based on 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 513 and Z 142.
Refer to C 513
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. Findings include, but are not limited to:
During a tour of the facility on 8/9/21, the following was observed:
All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats.
On 8/10/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director). They acknowledged the findings.
1. Action to correct this violation is to purchase new dining room chairs, and tables for Cottages Rose, Daisy, and Lilly.
2. This system will be corrected by closely monitoring the condition of furnishings within the cottages, and replace as needed in a timely manner.
3. This area will be monitored quartely at the beginning of each quarter, during the months of January, April, July, October.
4. The Administrator will be responsible for the corrections and monitoring.
Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows and furniture) and all equipment necessary for the health, safety and comfort of the resident was clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
During a tour of the facility on 11/29/21, the following was observed:
All dining room tables and chairs in Rose, Daisy and Lilly cottages were missing varnish on the table tops and legs. Multiple dining room chairs had stains on the fabric seats.
On 11/30/21, the need to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents were clean and in good repair was discussed with Staff 1 (Administrator). She acknowledged the findings.
1. Actions taken to correct this violation is to ensure all tables will be sanded and revarnished. All chairs will be cleaned and chairs will be sanded and revarnished if needed.
2. An audit will be conducted of community furniture monthly by maintenance to ensure that all furniture is in working and good condition.
3. Training will be done with staff to ensure they know how to report maintenance issues.
4. The Administrator will ensure all audits and mainenance request are being followed up with and completed timely.
There are no detail notes for this visit.
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 C231, C420 and C513.
Refer to C231, C420 & C153
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 513.
Refer to C 513.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff completed all required pre-service orientation prior to beginning job duties, and 2 of 2 long term staff completed the required number of hours of annual training. Findings include, but are not limited to:
Staff training records were reviewed on 8/10/21 with Staff 2 (Regional Director).
a. Training records for Staff 7 (CG) hired 6/4/21, Staff 9 (CG) hired 4/5/21 and Staff 15 (CG) hired 2/1/21, lacked documented evidence the following pre-service orientation elements were completed:
* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Standard precautions for infection control;
* Fire safety and emergency procedures; and
* Written job description.
b. Training records for Staff 11 (MT) hired 10/2/17, and Staff 13 (CG) hired 7/9/18 lacked documentation of completion of 10 hours of training related to the provision of care in CBC and 6 hours of training related to dementia care annually.
The need to ensure all required training was completed within the specified time frames was discussed with Staff 1 (Administrator) on 8/10/21. She acknowledged the findings.
1. Actions taken to correct this violation is to ensure all new hires have the appropriate new hire paperwork, skills checklists, and new hire trainings completed prior to working on the floor. The community will record and monitor all monthly in-service staff trainings.
2. A thourough audit will be completed of all employee files, and items that are missing with be completed. All trainings will be kept in their individual employee files instead of scattered in different areas.
3. This area will be monitored quartely at the beginning of each quarter, during the months of January, April, July, October.
4. The Administrator and Business Office Manager will be responsible doe the corrections and monitoring.
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 C270 and C280.
Refer to C270 and C280