The findings of the re-licensure survey, conducted 03/28/22 through 03/29/22, 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 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 03/29/22, conducted on 06/30/22, 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 pre-service dementia training, was completed prior to providing services to residents for 3 of 3 newly hired staff (#s 11, 12 and 13) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were requested on 03/29/22.

Staff 11 (MT), hired 01/24/22, Staff 12 (CG) hire 12/25/21, and Staff 13 (CG) hired 01/25/22, lacked documented evidence of having completed all of the required pre-service dementia training.

The need for staff to complete required pre-service  dementia training, before working with residents, was reviewed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

1. All employees will be audited in order to ensure current employees meet the OAR requirments for pre-service. Each new employee are to complete all pre-service classes including 6 hours of dementia training before hands on training occurs.  

2. The system we have is good.  We just need better follow through with the management team.  The Assistant director does the new hire and the director will need to provide better follow up to ensure all classes are completed.

3.  This will require monthly auditing in order to maintain compliance of new hires.

4.  The Assistant Director and the Director of the building will ensure the corrections are made.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired caregiving staff (# 11) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 03/29/22.

There was no documented evidence Staff 11 (MA), hired 01/24/22 had demonstrated competence in medication administration. Staff 4 (LPN) immediately completed and documented medication pass training, including demonstration of competence.  

The need to ensure staff had documentation of demonstrated competence in all job duties within 30 days was reviewed with Staff 1 (RCC/Administrator Designee), Staff 2 (Regional Director of Operations) and Staff 4 (LPN). They acknowledged the findings.

1. An audit will be completed to identify any missing documentation.  Care staff are to demonstrate satisfacotory performance

2. The director and staff LPN/RN will work together to ensure that all classes and competencies are shown before any new medication aide is signed off by the staff LPN/RN   

3. The are will need evaulation when there is a new med person added to the med room.  The staff delegations are resigned every 6 months with the staff RN.

4.  The staff LPN and RN need to ensure proper competency is shown and then documentation is then to be put in the delegations book.  The director will follow up to ensure classes are completed and competency is shown with the LPN/RN

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 03/28/22. The following issue was identified as needing repaired:

Exterior sidewalks around the facility had multiple areas where the concrete was uneven, creating a trip hazard.

On 03/28/22, the building's exterior was toured with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

1. The Aspens will get a bid and complete the sidewalk repari to the exterior sidewalk areas that are uneven in order to abate the potential tripping hazard ares.

2.  The director will call and schedule a contractor for the above mentioned repairs.

3. The director will make quarterly walk throughs in order to identify potential hazards in the future so they can be repaired in a timely manner.

4.  The director will be in charge of scheduling a contractor to make the repairs.  

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:

The facility was toured on 03/28/22 at 11:30 am. The following issues were identified:

* Dings, gouges, dents and scratches on multiple doors and door frames;

* Broken tile molding in numerous areas in the dining room; and

* Scratched, gouged, and dented handrails throughout the facility.

The areas needing repair were reviewed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged the findings.

1.  The Aspens will repair the dings, gouges and door frames.

The broken tile molding in the dining room will be repaired.  

The scratched, gouged and dented handrails in the faciltiy will be repaired.  

2. The maintenance man will be assessing potential areas of repair as part of his quarterly evaluations.

3. The maintenance man and Director will be doing quarterly evaluations in order to maintain the building

4. Director and maintenance man will be in charge of identifying potential safety hazards in order to abate them in the future.   

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system to alert staff when residents exited the facility. Findings include, but are not limited to:

The Assisted Living  had a main entrance, three additional doors by which residents could exit the building, and three doors which exited to an enclosed courtyard.

The facility was toured on 03/28/22. There was no system in place which alerted staff when a resident exited the facility.

The need to have a system which alerted staff when residents exited the building was discussed with Staff 1 (RCC/Administrator Designee) and Staff 2 (Regional Director of Operations). They acknowledged there were no door alarms or other systems in place to alert staff when residents exited.

1. All exit doors will have an alarm that will alert staff when residents exit the facility.

2. There will be alarms placed on all exit doors.  

3.  Alarms will be checked on a monthly basis to ensure they are working properly.

4.  Director/Maintenance will be responsible to ensure the corrections are completed and monitored.