The findings of the re-licensure survey, conducted 07/24/23 through 07/26/23, 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 OARs 411 Division 004 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

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 revisit to the re-licensure survey of 07/26/23, conducted on 11/02/23, 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 observation and interview, it was determined the facility failed to ensure medical records were kept confidential. Findings include, but are not limited to:

During an interview on 07/26/23 with Staff 2 (Wellness Director/RN) it was revealed the process to update staff on all shifts of a temporary service plan or health care information was to send a group message to the personal phones of all caregivers.

During interviews with Staff 4 (LPN/Clinical Coordinator), Staff 7, and Staff 8 (MT's) on 7/26/23, they explained messages related to resident conditions were sent directly to their personal cell phones, including health information.

The failure to ensure resident information was kept confidential was discussed with Staff 1 (ED) on 07/26/23. She acknowledged the findings and immediately discontinued use of the application to communicate resident status.

Based on observation and interview, it was determined the facility failed to ensure medical records were kept confidential.

The Correction:

1) All staff were removed from the group texting on the WhatsApp and that thread has been deleted. No resident information is shared on staff personal phones.

2) Facility purchased devices to communicate falls, and other emergencies, with the RN, Administrator and RCC/LPN securely while on the property of Juniper Springs. These devices are checked out each shift between the Med-Techs and checked back in after each shift, these devices are the property of Juniper Springs and does not leave the secure network of the building.

Based on observation, interview and record review, it was determined the facility failed to ensure an assistive device with restraining qualities was assessed by an RN, PT, or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the device for 1 of 1 sampled resident (#6) who had a side rail on their bed. Findings include, but are not limited to:

Resident 6 was admitted to the facility in 06/2023 with diagnoses including heart failure and was legally blind.

During the survey, Resident 3 was observed with a side rail constructed of PVC pipe in the up position on the bed.

Resident 6's "Growth and Wellness Plan" dated 07/20/23 noted "yes, an assistive device with potential for restraining qualities will be used. What type of device will be used?: bed cane"

There was no documented evidence of:

* Assessment completed by a RN, Physical Therapist, or Occupational Therapist;

* Other less restrictive alternatives attempted prior to use; and

* Instructions for caregivers on the correct use and precautions related to use of the device.

The lack of an assessment and documentation requirements for the side rail was discussed with Staff 1 (Executive Director), Staff 2 (Wellness Director/RN), and Staff 4 (LPN/ Clinical Coordinator). They acknowledged the findings.

Based on observation, interview and record review, it was determined the faility failed to ensure an asssitive device with restraining qualities was assed by an RN, PT or OT prior to use, and instruction was provided to caregivers on precautions and correct use of the dvice.

The Correction:

1) Assessment was completed on resident with the findings mentioned above on 7/28/2023.

2) All residents have been audited between 7/28/2023 and 8/8/2023 for assessments for devices.

3) On each move-in assessment with the resident or family the RN will make note of any assistive devices that is reported and place resident on the excel spreedsheet with the move in date to ensure an assessment is followed up on upon move in day.

4) Upon move in within 24 hours for each new resident, the RN will meet with the resident in their apartment and go over the care plan as well as assess the room to ensure that no devices were brought in after the move in assessment to ensure that she does not miss an assessment for devices.

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

The exterior of the facility was toured on 07/24/23. The following issue was identified as needing repaired:

* Exterior sidewalks around the facility, sidewalk outside exit doors,  and pathways in the interior courtyard had drop offs up to six inches measured from the concrete to the ground. These drop-offs created potential hazards for residents; and

* A section of the sidewalk in the interior courtyard had settled and sunk creating an uneven surface and a possible tripping hazard.

On 07/24/23, the building's exterior was toured with Staff 1 (Executive Director) and Staff 5 (Maintenance Director). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exteroir pathways and accesses were maintained in good repair; exterior sidewalk outside exit doors and pathwqays in the interior courtyard had drop offs up to six inches measured from the concrete to the ground. A section of the sidewalk in the interior courtyard had settled and sunk creating an uneven surface and a possible tripping hazard.  

1) Bark dust quotes were obtained on 6/4/2023. This has been approved.

2) Concrete for the sidewalk in they courtyard will be fixed on: 9/1/2023.

3) Bark on all other walkways around the facility will be installed by 9/24/2023.

4) Two yellow caution plastic standing signs with caution tape over it along with with two orange cones in the middle of the two caution signs have been placed for resident safety on 7/27/2023.

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 two doors that exited into the facility's inner courtyard and five doors to the exterior of the building, including the front entrance doors. The doors either lacked a device, or the device in place was not operational, to alert staff when residents left the building.

On 07/24/23, the exit doors were observed with Staff 1 (ED) and Staff 5 (Maintenance Director). They confirmed there was no system to alert staff when residents exited the facility.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming deice or other acceptable systems to alert staff when residents exited the building.

1) Alarms were installed on 7/24/2023 to the courtyard and other five doors to the exterior of the building including the front entrance.

2) A task reminder was installed on the reception computer email on 8/8/2023 to check batteries each month.

3) The front door chime is off during the day while recetpiton is at the front.

4) A task reminder has been added to the reception computer email to turn the chime back on the front doors before reception leaves for the day.

5) All staff have been communicated with and trained on how to remove the battery and replace them when needed and where batteries are kept on 8/8/2023.

6) Maintenance will keep batteries stocked in the reception area for easy access for all staff.