The findings of the re-licensure survey, conducted 05/30/23 through 06/01/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 06/01/23, conducted on 08/14/23, 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 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 initial move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 was admitted to the facility in April 2023. The following required elements were not addressed in the initial evaluation:

* Customary routines, such as those related to sleeping, eating, and bathing;

* Personality, including how the person copes with change or challenging situations;

* History of dehydration; and

* Environmental factors that impact the resident's behavior.

On 05/31/23 and 06/01/23, the need to ensure the initial move-in evaluation addressed all required elements was discussed with Staff 1 (ED) and Staff 2 (RN). They acknowledged the findings.

C252 OAR 411-054-0034 (1-6) Resident Move-in and Eval: Res Evaluation-

1.) The following actions have been taken to correct this violation, per each example listed:

Facility has utilized Point Click Care to address elements that were not acknowledged on the initial evaluation form. The facility will document * Customary routines, such as those related to sleeping, eating, and bathing. * Personality, including how the person copes with change or challenging situations. * History of dehydration and * Environmental factors that impact the resident's behavior.

2.) This system is being corrected by:

a. Continuing to work with Point Click Care to add elements to the evaluation.

b. The person completing the evaluation will manually type all missing elements into the evaluation in the last space provided on the form until more elements are added into Point Click Care.

3.) The facility Administrator and RCC will be responsible for correctionsand overseeing ongoing compliance. Home office IT will continue to offer support during the transitition to Point Click Care.

This will be monitored at move-in and at each evaluation update (ie: pre-move, move-in, 30-days, and 90 days/ Quaterly).  

Based on observation, interview, and record review it was determined the facility failed to ensure 3 of 3 sampled residents' service plans (#s 1, 2, and 4) were reflective of resident care needs and provided clear direction to staff. Findings include, but not limited to:

1. Resident 1 was admitted to the facility in 08/2022 with diagnoses including diabetes and neuropathy.

Resident 1's bed was observed bi-lateral 1/2 side rails in the up position.

Resident 1 had an electric scooter and a  manual wheel chair with a seat cushion.

In an interview on 5/31/23, Resident 1 explained the side rails were used for moving in bed. The resident said the electric scooter was used for longer distances and the manual wheel chair was used in his/her room.

Resident 1's service plan lacked clear instructions for caregivers for wheelchairs, and seat cushion and the use of the side rails, including precautions and risks.

The need for service plans to provide clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/30/23 and 05/31/23. They acknowledged the service plan lacked clear caregiving instructions.

2. Resident 2 was admitted to the facility in 02/2020 and was receiving hospice services.

On 5/30/23, Resident 2's bed was noted to have a transfer bar on the left side. An O2 concentrator was on and set to 2 lpm. The tubing was removed and lying on the bed.

In an interview on 5/30/23, Resident 2 explained the transfer bar was used for getting out of bed. Resident 2 stated facility and hospice staff assisted with the O2, explaining s/he had removed it to eat.

Resident 1's service plan lacked clear instructions for caregivers for the use of the transfer bar, including precautions and risk, and the O2.

The need for service plans to provide clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/30/23 and 05/31/23. They acknowledged the service plan lacked clear caregiving instructions.

3. Resident 4 was admitted to the facility in 07/2022 with diagnoses including diabetes.

Resident 4 was observed to mobilize independently using a power scooter.

Resident 4's bed was observed with bi-lateral 1/4 padded side rails in the up position.

Review of Resident 4's record revealed multiple injures to lower extremities, possibly caused by running into things with the power scooter.

Resident 4 was noted to use O2 and to have low oxygen saturation levels at times.

In an interview with Staff 4 (MT) on 06/01/23, she said Resident 4 had fragile skin and bruised and got skin tears easily.

Resident 4's service plan lacked clear direction to staff for the use of the side rails, including precautions and risk, O2 use, and precautions for fragile skin.

The need for service plans to provide clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (RN) on 05/30/23 and 05/31/23. They acknowledged the service plan lacked clear caregiving instructions.

C 260 OAR411-054-0036 (1-4) Service Plan: General -

1.)The following actions have been taken to correct this violation, per each example/resident listed: Facility is doing a thorough chart/resident/ apartment review of resident #1, 2, 3, and 4 to provide clear instructions to caregivers for wheelchairs, seat cushions, the use of side rails including precautions and risk, and Oxygen use. Also, clear instructions for precautions in regards to handling individuals with fragile skin.

2.)This system is being corrected as follows:

a.           Facility RN will stay current on Supportive Device Evaluations, Restraint Assessments, and risk assesments.

b.           Always updating as Third Parties (ie: doctor, home health, or hospice) prescribe new devices to help the resident (ie: oxygen, side rail, transfer bars).

c.RN will hand write into Service Plans after alerting Administrator of all new changes.  

d.All hand written changes on the Service Plans will be entered electronically on the date of the resident's next Service Plan Meeting.

e.RN will write clear instructions into Service Plans for residents with fragile skin who need precautions. All handwritten notes on the Service Plan will be added electronically at the resident's next Service Plan.

f.            All oxygen care and instructions not carried over from the eval to the Service Plan in Point Click Care will be manually added. If oxygen is a new order, it will be handwritten in by the RN on the Service Plan and added electronically on the resident's next Service Plan meeting date. This will be monitored daily/weekly/ monthly/ Quaterly.

3.) The facility Administrator and RN will be responsible for corrections and overseeing ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly hired staff (#s 4, 5, and 6) completed the pre-service Infectious Disease Prevention training curriculum. Findings include, but are not limited to:

Training records for Staff 4 (MT), hired 02/18/23, Staff 5 (CG), hired 04/13/23, and Staff 6 (CG), hired 03/07/23,were reviewed with Staff 3 (Administrative Assistant) on 05/31/23.

There was no documented evidence Staff 4, 5, and 6 had completed all of the required pre-service Infectious Disease Prevention training curriculum.

The need to ensure staff completed all required pre-service training was discussed with Staff 1 (ED) on 05/31/23. She acknowledged the findings.

C 370  OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiving Rqmts-

1.)The  following actions have been taken to correct this Violation:

All staff have been assigned the missing pre-service Infectious Disease training curriculum through Relias. It is being tracked and documented.

2.)This system will be evaluated  by the Administrator and Assistance Administrator.

3.) This will be monitored weekly/monthly.

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. Findings include, but are not limited to:

On 05/31/23, the surveyor discussed the facility's process and documentation for instructing residents on fire and life safety procedures with Staff 1 (ED). Staff 1 explained the instruction was provided to residents verbally upon admission and there was no documented evidence the information was provided.

Staff 1 acknowledged annual resident re-instruction in fire and safety procedures had not been documented as done.  

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instruction at least annually, maintaining a written record of the training, including content and the residents attending, was discussed with Staff 1. She acknowledged the findings.

C422 OAR 411-054-0090  (5)  Fire and Life Safety: Training for residents-

1.)The following actions have been taken to correct this violation:

a.Administrator and Resident Care Coordinator will review in the first 24 hours of admission and re-instruct all residents once a year on general safety procedures, evacuation methods, responsibilities during fire drills, and the location of designated meeting areas outside the facility or within the fire safe area in the event of an actual fire.

2.)      The facility Administrator and Resident Care Coordinator will be responsible for correction        and documentation and overseeing on-going compliance.

3.) This will be monitored at each new move-in and monthly.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 05/30/23. The following issues were identified as needing repaired in the interior courtyards and at exterior exit doors:

* Multiple drop offs up to 4 inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents.

* Concrete edging pavers were removed and placed on the pathway creating a tripping hazard.

* The sidewalk was damaged creating tripping hazards.

On 05/30/23, the building's exterior was toured with Staff 1 (ED). She acknowledged the findings.

C-610 OAR 411-054-300 (3) (a-h) General Building Exterior-

1.)The following actions have been taken to correct this violation:

All drop offs have been eliminated with the use of pavers, bark dust, and gravel.

2.)When work is being done in an area such as the courtyard all areas will be clear to ensure safety from trip hazzards.

3.)The sidewalks have been repaired eliminating trip hazards.

4.)The facility Administrator and Head of Environmental Services/ Maintenance will be responsible for corrections and overseeing on-going compliance.

5.) This will be monitored daily.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable systems to alert staff when residents exited the building. Findings include, but are not limited to:

During the survey, the facility was identified to have five doors that exited into the facility's inner courtyard and four doors exiting to the exterior of the building. The exit doors lacked an alarming device to alert staff when residents left the building.

On 05/30/23, the lack of alarms or other acceptable system was shared with Staff 1 (ED). She confirmed there was no system to alert staff when residents exited the facility.

C655  OAR 411-054-0300 (11-13) Call System-

1.)The following actions have been taken to correct this violation:

Doorbells have been bought and installed on all exit doors leading into courtyards and all emergency exit doors leading leading to the exterior of the building.

2.)The facility Administrator and Head of Environmental Services/ Maintenance will be responsible for corrections and overseeing on-going compliance.

3.) Environmental Services will monitor monthly to ensure doorbells are working.

.