The findings of the initial survey conducted 08/30/22 through 09/01/22 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 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

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 to the re-licensure survey of 09/01/22, conducted on 12/13/22, 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 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 staff were following safe food handling practices and food storage was in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

a. During observations of two cooks and the lunchtime meal preparation process on 08/30/22 and 08/31/22, the following issues were identified:

* A cook failed to use a proper sanitation solution when wiping down food preparation surfaces; and

* A cook did not disinfect the probe thermometer between testing different food items.

b. During observations of the lunchtime meal service in the dining room on 08/30/22 and 08/31/22, the following issues were identified:

* Direct care staff were not provided clean aprons prior to serving residents; and

* Staff failed to consistently sanitize their hands or don gloves prior to serving residents and failed to sanitize or change gloves after touching potentially contaminated surfaces, including the residents themselves, residents' wheelchairs, pagers and the kitchen door.

c. Observation of the facility dry storage area and walk-in refrigerator indicated multiple food items were not sealed, labeled and dated once the package was opened. Scoops were left in large bins where brown sugar and flour were stored.

The need to ensure that the facility follows safe food handling and proper food storage practices in accordance with the Food Sanitation Rules OAR 333-150-0000 was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 5 (Business Office Manager) on 09/01/22 at 9:45 am. They acknowledged the findings.

1. Kitchen area; Store, label food properly, ensure staff follow food handling practices. All food items (ingredients too) will be stored and labled properly and in the correct containers. All refrigerated and frozen food items will be marked with the correct dates, this also includes food items stored at room temperature.

2.Executive Director and Dietary Manager will conduct training with all kitchen staff and direct care staff regarding the proper storing, labeling and food handling practices. This will be done at next all staff meeting set for Wednesday October 5, 2022.  Kitchen in-services will be added to the yearly calendar and training will be done quarterly with all staff regarding "Best Practices in the Kitchen and Dining Room". Or as needed.

3. The kitchen area will be monitored daily by the Dietary Manager and cooks. Executive Director will be checking weekly to be sure these items are being implemented and working properly.

4. Dietary Manager will be responsible for the Kitchen and Dining Room area. Assisting the DM will be the Executive Director.

Based on interview, it was determined the facility failed to choose and implement an Acuity-Based Staff Tool (ABST) by July 1, 2022 to determine appropriate staffing levels for the facility. Findings include, but are not limited to:

On 08/31/22, Staff 1 (ED) was asked to provide evidence the facility had implemented an ABST to determine appropriate staffing levels for the facility. Staff 1 stated the facility had not implemented an ABST.

The need to ensure the facility implemented an ABST was reviewed with Staff 1 and Staff 2 (RN) on 08/31/22. They acknowledged the findings.

1. Implement Acuity Based Staffing Tool (ABST); Currently working on this tool and have been in touch with Kelsie Norton - Corrective Coordinator (SOQ) As of 9/26/2022 I will be calling her with an update regarding ABST and due date.

2. It will be corrected right away and will continue using the tool permanately and will follow the Oregon rules regarding this tool and will coninue to stay in touch with the SOQ office if I have questions or need futrure training or updates.

3.Currently the tool will be monitored daily until it has been completed and once done it will be updated as need according to move-ins/move-outs, updated  changes in Resident Care Plan or any other modifications that need to be completed. The tool will be evaluated at least weekly and again as needed.  

4.The ABST will be the responsibility of the Executive Director and the Director of Nursing Services.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 3 of 4 newly-hired staff (#s 9, 12 and 13) and infectious disease prevention training was completed for 2 of 2 veteran staff (#s 18 and 19). Findings include, but are not limited to:

On 08/30/22 and 08/31/22 training records were reviewed with Staff 5 (Business Office Manager).  

The following deficiencies were identified:

a. Staff 9 (Kitchen Aide) was hired on (07/15/22). Staff 9 had not completed pre-service training in the following areas prior to beginning her job responsibilities:

*Resident rights and values of CBC care;

*Abuse reporting requirements;

*Infectious disease prevention training was not completed by July 1, 2022;

*Fire safety and emergency procedures; and

*Written job description.

b. Staff 12 (MT/CG) was hired on 04/14/22. Staff 12 had not completed pre-service infectious disease prevention training prior to beginning her job responsibilities.

c. Staff 13 (CG) was hired on 07/28/22. Staff 13 had not been provided a written job description prior to beginning her job responsibilities.

d. Staff 18 (CG) was hired on 08/22/21 and Staff 19 (MT/CG) was hired on 08/27/21. They had not completed infectious disease prevention training by July 1, 2022.

The need to ensure that all newly hired staff completed pre-service orientation training prior to beginning their job responsibilities, and veteran staff completed infectious disease prevention was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22. They acknowledged the findings.

1. Ensure Orientation training and new "Infectious Disease and Control"; All orientation training and classes must be completed upon hire or we will ask for current up to date certfications (copies). We will continue to check in with staff (texting/calling) until they complete the classes and training that is required.

2. Upon hire and all currently staff have been instructed regarding the training tool we use for all staff training including "Infectious Control. Oregon Care Partners and Relias Learning is the tool we use. All staff are expected to complete the training we have set up for them. We will be posting flyers and reminding staff weekly regarding their expected training and completion of assigned topics. Facility has implemented a computer-based tracking program that will track all staff training.

3. All New Hire Orientation will be completed within the 4-7 days of starting new postion, this includes the "Pre-Service Infectious Disease Prevention and Control for Community Based Care" certificate. Current employees who have not completed the Infection Control training will have until October 5 to complete the training.

4. Business Office Manager, Resident Care Coordinator and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 11 and 13) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 08/30/22 and 08/31/22 revealed the following:

* Staff 11 (CG) was hired 04/29/22 and Staff 13 (CG) was hired 07/28/22. There was no documented evidence those staff completed First Aid and abdominal thrust training within 30 days of hire.

The need to ensure all newly hired staff completed First Aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22.  They acknowledged the findings.  

1. Ensure staff complete First Aid Training. Upon new hire and monthly all staff meeting, we will be discussing staff training and requirements. Next month (October 2022) we have an instructor that willl be coming to teach CPR/First Aid/Abdomianl Thrust.  

2. We have a new computer tracking system that will help us assist with tracking all employees training and certifications that are due or close to expiring. It produces a monthly report of what staff training or certificates are due.

3. We will be checking WEEKLY and upon hire that training with staff is getting completed.  

4. Business Office Manager and Resident Care Coordinator will be responsible for staff training; Med-Techs and Direct Care Staff, also includes all Managers.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 veteran direct care staff (#15) completed a minimum of 12 hours of in-service training annually, including 6 hours on dementia care. Findings include, but are not limited to:

Review of the facility's training records on 08/30/22 and 08/31/22 revealed the following:

*Staff 15 (MT/CG), hired on 06/23/21, did not have documented evidence of 6 hours of annual in-service training related to dementia care.

The need to ensure all staff have a minimum of 12 hours of in-service training annually on topics related to the provision of care for persons in a CBC, including 6 hours on dementia care topics, was discussed with Staff 1 (ED) and Staff 5 (Business Office Manager) on 08/31/22.  They acknowledged the findings.

1. Annual training: upon new hire and monthly all staff meeting, we will be discussing staff annual training. We will also include in-services at staff meetings. This will include some of the (6) hours of dementia training. And (6) hours of training related to direct care. We will be keeping track of each employee in the annual training CEU binder.  

2. New hires and current staff have been introduced to our Staff Training Tool - Oregon Care Partners and Relias Learning. All the annual training is included  in this training tool and staff will be expected to complete it in a timely manner base on Oregon ALF/RCF rules. We have a new computer tracking system that will help us assist with tracking all employees training and certificates that are due or close to expiring. It produces a monthly report of what staff training or certificate are due.. This will help us to be sure staff gets it completed.  

3. We will be checking WEEKLEY that annual training with staff is getting completed. Also upon hire we will discuss with new staff.

4. Business Office Manager and Resident Care Coordinator will be responsible for staff completing all annual training.

Based on interview and records review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 01/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:

*Problems encountered, comments relating to residents who resisted or failed to participate in the drills.  

In an interview on 08/31/22, Staff 1 (ED) stated the facility evacuated residents as part of the fire drill process, however, it was not including documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills. Staff 1 stated that he met individually with those residents who did not participate in the drills, however, he did not document the content of those meetings.

The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 on 08/31/22.  Staff 1 acknowledged the findings.

1.Ensure documentation for non-participating residents who didn't participate in fire drills. Training will be conducted with Business Office Manager and Maintenance Director immediately by Executive Director so they have an understanding of how to document non-participating residents for future fire drills. All (3) managers will be trained in fire drill procedures in case the other one is away or out of the building in all future fire drills and training. This includes all monthly documention and fire log procedures.

2. Fire drills will be conducted monthly with rotating months with training and alternating shifts so that all (3) shfits are covered and all staff receives fire drill training. And alll fire drills are documented including non-participating residents.

3. Documentation will be evaluated monthly.   

4. Executive Director, Busniess Office Manager and Maintenane Director will be responsible for making sure this documentation is accurate and complete.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in locked storage.  Findings include, but are not limited to:  

On 08/30/22 at 9:45 am, the surveyor conducted a walk-through of the facility and was able to access two unlocked closets containing toxic chemicals. The closets were located near resident rooms and could be accessed by residents.

During a follow-up on 08/31/22 at 10:20 am, the storage closets were still observed to be unlocked.

The need to ensure chemicals and toxic materials were secured in locked storage was discussed with Staff 1 (ED). He acknowledged the findings.

1. Maintenance was able to repair the lock on the janitorial padlock door - the battery had died. The door lock for the storage room; we had to readjust the locking bar on top of the door so that it would lock easier once door was closed.

2. We will be checking on the doors daily to be sure the doors are properly locked and functioning well.  

3.We will check on the doors daily to be sure they are working properlty and are locking accurately when the door is shut.

4. Executive Director, Resident Care Coordinator, Business Office Manager and Maintenance will be responsible for maintaining the proper locking of the janitorial and storage room doors.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units were maintained within a range of 110 and 120 degrees Fahrenheit.  Findings include, but are not limited to:  

On 08/30/22, the surveyor measured water temperatures in four resident units.  The hot water temperature ranged from 96.3 to 132.3 degrees Fahrenheit.  Staff 5 (Business Office Manager) and Staff 21 (Owner) were present for testing of the water temperatures.

On 09/01/22, Staff 21 informed the surveyor that the temperatures had been adjusted the previous evening. The surveyor retested the same units and found the temperatures to be within the range of 110.2 and 117.2 degrees Fahrenheit.  

The need to ensure water temperatures in resident apartments were maintained within the required range was discussed with Staff 1 (ED) on 08/31/22. Staff 1 acknowledged the facility needed to implement a system for monitoring water temperatures.

1. Water temperatures in the residents apartments will be maintained within a range of 110-120 degrees Fahrenheit. This will be done weekly. We have a dedicated  person (see below) they will be filling out the water temperature log sheet, this will be filed in our Water Temperature log binder.

2. Our designated team member will be alternating resident rooms based on sections. The temperatures will be logged on our water temperature sheet and completed once every week. Maintenace willl be assisting with the training so it's done correctly and accurately.

3.The water temperatuers will be compled WEEKLY.

4.Maintenance and/or Lead Direct Care staff member will be responsible for checking the water temperatures in the residents rooms.  Executive Director will looking at the Water Temperature Log Book on a weekly Basis.