The findings of the relicensure survey conducted 01/19/22 through 01/20/22 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, 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

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 first re-visit of the re-licensure survey of 01/20/2022, conducted on 04/06/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The kitchen was toured on 01/19/22 and 01/20/22 with Staff 4 (Dietary Manager). The following areas were in need of cleaning or repair:

* There were cracked floor tiles beside the grease trap and between the steam table and warewashing station;

* The grease trap cover had brown and black matter build-up with a rust colored substance on it;

* The grease trap's cover was not secure and was reported to lift off when the trap was full;

* The warewashing machine manufacturer's plate stated chemicals were used for the sanitization process, but there were no testing strips available for staff to be able to ensure  sanitization; and

* The storage area under the steam table was pealing which made it an uncleanable surface.  

The areas needing cleaning and repair were discussed with Staff 1 (Executive Director) and Staff 4 on 01/20/22. They acknowledged the findings.

Grease trap cover was removed immediately, and a temporary cover placed that fit more securely. Obtaining quotes to replace broken tile and refinish storage area under the steam table.

When ordering test strips for the warewashing machine the Dietary Manager recalled that the machine does not use chemicals in the sanitation process, we then confirmed with Eco Lab that we in fact use high heat sanitation. Therefore, there are no strips for testing.  

Dietary staff will place any repairs needed on the maintenance log immediately upon noticing something is not working or needs repair. Monthly walk through of the kitchen to monitor all areas and equipment are clean and in good repair. In the event something is found to be in need of repair it will be placed on the maintenance log immediately.

Daily and Monthly

Dietary Manager, Maintenance Director, Executive Director.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from 04/30/21 to 11/29/21. The following deficiencies were identified:

1. The facility failed to relocate or evacuate residents during fire drills and failed to ensure fire drills were being done in the unit every other month. Therefore, documentation was lacking in the following areas:

* The escape route used;

* Residents who resisted or failed to participate in the drills;

* Evacuation time period needed; and

* The number of occupants evacuated.

2. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 01/19/22. They acknowledged the findings.

Created a new form that covers all areas of Fire and Life Safety requirements. Reviewed and Implemented with the Maintenance Director the requirements and schedule for training and actual drills.

Maintenance Director will provide Fire and Life Safety training upon hire to all new employees. Will follow annual calendar rotating training and drills every other month. For drills, updated form will be filled out completely hitting all areas required, including signature from staff that participated. Training will be documented on In-Service Training Sheet.

Monthly

Maintenance Director and Executive Director  

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety training was provided to residents and staff. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from 04/30/21 to 11/29/21 and lacked documentation of the following required components:

* Evidence alternative exit routes were used during fire drills;

* Staff's knowledge of the designated point of safety;  

* Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and

* Documentation of interventions and/or resolution related to resident evacuation concerns identified during fire drills.

The need to ensure general fire and life safety training was provided to residents and staff was  discussed with Staff 1 (Executive Director) and Staff 5 (Maintenance Director) on 01/19/22. They acknowledged the findings.

Created a new form that covers all areas of Fire and Life Safety requirements. Reviewed and Implemented with the Maintenance Director the requirements and schedule for training and actual drills.

Maintenance Director will provide Fire and Life Safety training upon hire to all new employees. Will follow annual calendar rotating training and drills every other month. For drills, updated form will be filled out completely hitting all areas required, including signature from staff that participated. Training will be documented on In-Service Training Sheet.

Monthly

Maintenance Director and Executive Director  

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

During a tour of the facility on 01/20/22, the following was revealed:

* An upholstered chair outside room 162 had brown stains and streaks on the cushion and arm; and

* A loveseat outside room 160 had stains that were on both cushions and went up both arms.  

In interview on 01/20/22 at 1:59 pm, Staff 3 (RN Consultant) stated various staff had asked Staff 5 (Maintenance Director) to clean the furniture, but it had not been done.

The concern of the soiled furniture was shared with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings and stated the facility had removed the furniture until it could be cleaned or replaced.

Both the couch and loveseat were removed immediatly from ECU.

A weekly check will be done every Tuesday of all furniture with a list being given to Maintenace for cleaning.  In the event an accident or spill occurs throughout the week it will be added to the Maintenance log for cleaning. If Maintenance is unable to clean the same day, the item will be taken to the garage until it can be cleaned the next day.

Daily for accidents and spills, weekly for upkeep.

ECU Administrator and Executive Director.

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 C 240, C 420, C 422 and C 513.

Refer to CBC Plan of Correction for C240.

Refer to CBC Plan of Correction for C420.

Refer to CBC Plan of Correction for C422.

Refer to CBC Plan of Correction for C513.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled direct care staff (#s 6, 11 and 12) completed a total of 16 hours of in-service training annually, including six hours of annual dementia care training. Findings include, but are not limited to:

Training records for 1/1/2021 through 12/31/2021 were reviewed on 01/20/22. The following deficiencies were identified:

Staff 6 (CG) hired on 03/07/14, Staff 11 (CG) hired on 11/01/11, and Staff 12 (CG) hired on 11/08/19 did not have documented evidence of completing the required 16 hours of annual in-service training.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Executive Director) on 01/20/22. She acknowledged the findings.

Pre-Service and Continuing Education and Training Policy and Procedure has been revised to comply with training requirements.

Attendance and Education Binders have been created and given to all managers to track timely completion of annual in-service training. Monthly in-service classes will be posted by the 10th of each month, to be completed by the 25th of each month. Staff to turn in certificate upon completion to their manager, manager will log on individual In-Service Tracking Sheet. Managers to audit binder around the 25th of each month, remind staff as needed of annual training requirements and the importance of completing timely.

Binder will be audited each quarter to ensure staff are completing annual training timely.

Managers and Executive Director