The findings of the change in ownership survey, conducted 06/10/24 through 06/12/24, 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 for 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 re-visit to the change of ownership survey of 06/12/24, conducted 11/18/24 through 11/19/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

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

1. Resident 3 moved into the facility in 03/2024 with diagnoses including end stage renal disease.

The resident's service plan, updated 05/22/24, and progress notes, dated 03/27/24 through 06/07/24, were reviewed. Staff and Resident 3 were interviewed. The service plan was not reflective of the resident's current needs or provided clear direction to staff in the following areas:  

* Mobility device used;

* Spouse and dog living at the facility;

* Sleeping routine;

* Current skin issues;

* Who was responsible for ordering oxygen supplies; and

* PRN staff assistance to apply barrier cream.

The need to ensure service plans were reflective of resident needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN), and Staff 3 (RCC) on 06/12/24. They acknowledged the findings.

2. Resident 1 moved into the facility in 05/2023 with diagnoses including vascular dementia.

Resident 1's service plan, updated 03/05/24, and interim service plans were reviewed. Interviews with care staff were conducted and observations of the resident were made. The resident's service plan failed to reflect the resident's care needs, provide clear instruction to staff, or was not implemented in the following areas:

* How often to perform safety checks;

* Mobility assistance including use of a wheelchair;  

* Number of staff needed to assist when using the toilet;

* Skin conditions including use of barrier cream with toileting changes;

* Meal assistance throughout the meal;

* Staff instruction to limit resistance to care; and

* Leaving the door propped open.  

The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were implemented was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing Services/RN) on 06/12/24. The findings were acknowledged.   

Resident 1's care plan  has been updated to reflect the resident's care needs and correct the deficency noted during the survey 7/11/24.

Resident 3's care plan has been updated to reflect the resident's care needs and correct the deficency noted during the survey 7/11/24.

Care plans will be reviewed by entire Care Planning Team during care conferences and changes of condition.

Each Care Plan has been printed, and made available for staff to make notes and alert Resident Care Coordinator to changes needed for care plans as well which will be reviewed daily in clinical meeting.

In addition to meeting quarterly during care conferences, Care Planning Team will meet weekly to audit (3) charts to ensure care plans are accurate and reflective of resident care needs for 7 weeks.  

The Executive Director will be responsible for ensuring the corrections have been implemented, and monitoring for continued compliance.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 1 of 1 sampled resident (# 1) who received incontinence care and meal assistance from staff, and meal service and delivery to sampled and unsampled residents. Findings include, but are not limited to:

Resident 1 moved into the facility in 05/2023 with diagnoses including vascular dementia.

Observations and interviews with staff during the survey identified the resident relied on staff for incontinence care needs, and required finger foods and meal assist.

a. During the survey, from 06/11/24 through 06/12/24, multiple care staff who performed universal duties, including resident ADL care, were observed to assist with meal assistance to Resident 1, provided meal service in the dining room, and meal delivery to resident units. Care staff were not wearing aprons or some other barrier to prevent the potential for cross contamination when assisting with meal service and delivery.

b. Lunch service was observed on 06/11/24 and 06/12/24.

Staff were observed serving meals and beverages, touching residents, removing dirty dishes and providing meal assist to Resident 1 without changing their gloves or performing hand washing.

c. During an ADL observation on 06/12/24 at 10:15 am the following was noted:

* Two caregivers donned their gloves and assisted Resident 1 to the bathroom. One caregiver assisted the resident to remain standing while the second caregiver doffed Resident 1's pants, removed the soiled brief, and put it in the trash can. Both caregivers assisted the resident to sit  on the toilet. Without changing the soiled gloves or performing hand hygiene, the caregiver retrieved a clean brief. Both caregivers then assisted Resident 1 to stand up, one caregiver provided personal care with wipes, donned the clean brief, and then touched Resident 1's pants, shirt, hand, arm and blanket. The caregivers were observed removing their gloves, leaving the resident's apartment, and then going to another floor. There was no observation of hand hygiene.  

The need to ensure staff consistently used universal precautions when providing incontinence care and meal service was discussed Staff 1 (ED), Staff 2 (Director of Nursing Services/RN) on 06/12/24. They acknowledged the findings.

All staff inservice completed 7/5/24 on infection prevention, need for aprons during meal service, and hand washing and glove changing.

Aprons have been ordered and received to ensure adequate supply available for staff daily 7/11/24.

Signs have been posted in dining rooms to remind staff to wear aprons and to change gloves when needed

Unannounced observation and audit will be conducted at least once weekly x 6 weeks, in dining room to ensure compliance with policy.  

Executive Director will be responsible for ensuring the corrections have been implemented and monitoring for continued compliance

Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, and written, signed physician or other legally recognized practitioner orders were documented in the resident's facility record for all medications and treatments that the facility was responsible to administer for 1 of 3 sampled residents (# 3) whose MARs and physician's orders were reviewed. Findings include, but are not limited to:

Resident 3 was admitted into the facility in 03/2024 with diagnoses including end stage renal disease.

The resident's 05/01/24 through 06/10/24 MARs and physician's orders were reviewed.

a. Staff were administering the following medications:

* Pramipexole (for restless leg) 0.5 mg once a day; and

* PRN APAP/Codeine (for pain).

There was no documented evidence of signed physician orders in the resident's facility record.

b. Resident 3 had signed physician's order for the following medications:

* Scheduled APAP/Codeine by mouth twice a day; and

* Ropinirole (for restless leg syndrome) 4 mg by mouth nightly.

The above orders had not been transcribed onto the resident's MAR nor was the resident receiving the medications.

The need to ensure physician's orders were carried out as prescribed and all written, signed orders were documented in the resident's record was discussed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN), and Staff 3 (RCC) on 06/12/24. No additional information was received.

Orders for Resident 3's pramipexole and PRN Apap/Codeine, with D/C order for Ropinerole have been received by facility and placed in chart.

Signed physician's orders reflecting all current orders will be obtained by date of compliance.

Going forward all electronic medication orders placed in EMAR by pharmacy will be audited to ensure a copy of order is received by facility.

This audit will occur weekly x 6 weeks, and then monthly.

Executive Director will be responsible for ensuring the corrections have been implemented and monitoring for continued compliance

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moves in, with amendments as appropriate within the first 30 days, whenever there is a significant change of condition, no less than quarterly, and failed to have an accurate number of minutes for 1 of 3 sampled residents (# 1) for residents whose ABST was reviewed. Findings include, but are not limited to:

a. Review of the facility's ABST, revealed not all residents had been entered before a resident moved in, or updated when there was a significant change of condition or no less than quarterly for 15 out of 19 residents.

b. Resident 1's medical record was reviewed, observations were made of the resident, and staff were interviewed. The number of minutes assigned relating to the ABST were inaccurate.

The need to ensure the ABST was updated before a resident moved in, whenever there was a significant change of condition, no less than quarterly, and the resident's minutes were accurate for the staffing plan to meet the 24 hour scheduled and unscheduled needs of residents was discussed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN), and Staff 3 (RCC) on 06/12/24. They acknowledged the findings.

Resident 1's ABST has been reviewed against service plan, and observation of staff providing care to ensure it is reflective of number of minutes needed.

The ABST tool has been reviewed by the Executive Director for each resident in the facility, and will be updated as needed

Going forward, the ABST tool will be reviewed prior to move-in, 30 days post move-in, at significant changes of condition, and at quaterly care conferences

The ABST tool will be monitored/evaluated monthly by the Executive Director to ensure the corrections have been implemented and maintained.

Based on interview and record review, it was determined the facility failed to ensure fire drills were documented with all required elements. Findings include, but are not limited to:

Fire drill records and fire and life safety training records from 06/11/24 through 06/12/24 were reviewed. The following deficiencies were identified:

The facility's fire drill form lacked the following documentation:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* Number of occupants evacuated; and

* Evidence that alternate escape routes were used during fire drills.

The requirements regarding fire drills and fire and life safety instruction for staff was reviewed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN), and Staff 4 (Maintenance) on 06/12/24. They acknowledged the findings.

Maintainence Director has been inserviced on Fire and Life Safety regulations pertaining to fire drills. Documentation has been updated to reflect documentation related deficencies noted during survey.

Appropriate fire drill has been performed for the month of June, and alternate In-service/Education for the Month of July.

Going forward, a schedule highlighting months needed for unannounced fire drillshas been established by Maintainence director.

Compliance with alternate month fire drills / education will be audited monthly at the Safety Committee meeting monthly.

The Executive Director is responsible for ensuring these corrections have been completed and monitored

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually. Findings include, but are not limited to:

Fire drill records, from 01/10/24 through 05/12/24, were reviewed on 06/11/24.

On 06/12/24 at 8:51 am Staff 4 (Maintenance) stated the facility was not providing or documenting annual instruction for residents 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.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 (ED), Staff 2 (Director of Nursing Services/RN), and Staff 4 on 06/12/24. They acknowledged the findings.

Annual Fire and Life Safety training has been completed for all residents in the facility for 2024 as of 7/5/24.

Going forward Fire and Life Safety resident training will be conducted yearly and audited monthly during Safety Committee Meeting to ensure compliance of annual education.

Executive Director will be responsible for ensuring completion of corrections, and monitoring ongoing compliance.

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

The facility was toured on 06/11/24 and the following was observed:

a. Exterior of building:

* Dirt and debris were found on patio furniture in the courtyard, smoking area, and front porch; and

* The front porch area had cobwebs, dirt, and debris noted on the windowsills and railings.

b. Interior of the building:

* Front doors had dings and gouges on the edges;

* Scuffs and dings on multiple resident doors;

* Laundry room had peeling paint on the wall above the drain and black stains near the faucet handles, one edge of the drain was peeling, and the interior of the drain was dirty with grey, brown and rust colored stains. The plastic cover plate to the waterline of the middle washing machine was cracked, not in place, and exposed a hole in the wall; and

* Two doors located in the dining room which lead into the courtyard were difficult to open.

The areas in need of cleaning and repair were reviewed with Staff 1 (ED) and Staff 4 (Maintenance Director) on 06/12/24. They acknowledged the findings.

The exterior patio furniture has been cleaned 7/5/24.

Maintainence has ordered supplies to correct the dings and gouges on the doors. Work to be completed on or before 8/11/24.

Maintainence has ordered parts to repair courtyard doors 7/5/24, work to be completed on or before 8/11/24.

Maintenance will order replacement basin, and will have laundry room deficiencies corrected by compliance date of 8/11/24.

Going forward Maintenance will add cleaning of patio furniture and exterior weekly, as well as facility tour for deficencies and will be audited by Executive Director weekly x 6 weeks, then monthly during safety/maintenance meeting.

Executive Director will be responsible for ensuring completion of corrections and monitoring ongoing compliance.

Based on observation and interview, it was determined the facility failed to provide closed containers that ensured the separate storage and handling of soiled linens and soiled clothing, and washers reached a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:

The facility laundry room was observed on 06/11/24 and 06/12/24. The three washing machines were of residential type with automatic laundry detergent dispensers. There were no indicators for the water temperature. The laundry detergent observed in the staff and resident-use laundry room did not contain a chemical disinfectant.

In an interview on 06/11/24 with Staff 10 (CG), she indicated soiled items with bodily fluids were delivered to the laundry room in the resident's laundry basket and the soiled items were loaded into the washing machine. "Sometimes they [soiled items] have to sit there because there are no machines available. I get them in as soon as a spot is open."  In an interview on 06/11/24 with Staff 8 (CG), she confirmed soiled items were delivered to the laundry room in the resident's laundry basket.

In an interview on 06/11/24 at 2:45 pm with Staff 1 (ED), he confirmed the laundry detergent did not have a chemical disinfectant.

In an interview on 06/12/24 with Staff 4 (Maintenance Director), he indicated the washing machines did not reach minimum rinsing temperatures of 140 degrees Fahrenheit.

The need to ensure the facility provided closed containers that ensured the separate storage and handling of soiled linens and soiled clothing, and washers had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical was used was discussed with Staff 1, Staff 2 (Director of Nursing Services/RN) and Staff 4 on 06/12/24. They acknowledged the findings.

Laundry washing detergent with color safe bleach has been ordered and received, and is the only laundry detergent being used going forward to meet chemical disinfectant.

Closed containers designated for soiled items only have been provided for the staff to use to ensure soiled items are transported and stored in laundry room covered.

Going forward Maintainence Director will audit laundry washing detergent monthly to ensure only the chemical disinfectant version is used in the facility. This will initially be monitored weekly x 6 weeks, and then monthly. Laundry room and soiled items will be randomly audited/monitored once a week x 6 weeks, and then monthly.

Executive Director will be responsible for ensuring completion of corrections, and monitoring ongoing compliance.

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 to 120 degrees Fahrenheit (F). Findings include, but are not limited to:

On 06/11/24, the surveyor measured water temperatures in unoccupied resident unit bathrooms and common area bathrooms throughout the assisted living units. The following were identified:

* Resident room 139 bathroom sink water temperature was 109.5 degrees F;

* Resident room 205 bathroom sink water temperature was 108.3 degrees F;

* Resident room 246 bathroom sink water temperature was 109.3 degrees F;

* Common area bathroom sink (first floor) water temperature was 103.6 degrees F; and

* Spa room/bathroom (second floor) sink water temperature was 71.4 degrees F.

In an interview on 06/11/24 with Staff 4 (Maintenance Director), he indicated that the mixing valves were replaced two months ago and they were working on finding the right setting for the water temperatures.

On 06/11/24 the need to ensure hot water temperatures were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 (ED ) and Staff 4. They acknowledged the findings.

Bid for (2) new recirculating pumps has been accepted, pumps have been ordered, and work will be completed by 8/11/24 to ensure adequate water temps throughout the facility.

Going forward, the Maintainence Director will audit room temperatures of (3) random hot water sources throughout the facility weekly to ensure adequate hot water temps and adjust as needed.

This audit will initially be done daily (5 days a week) x 6 weeks, and then moved to weekly.

Executive Director will be responsible for ensuring completion of corrections, and monitoring ongoing compliance.

Concerns were identified and the facility was provided with technical assistance in the following area:

H 1510 - Individual Rights Settings: Privacy, Dignity

OAR411-004-0020(1)(c)

(c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and the facility was provided with technical assistance in the following area:

H 1517 - Individual Privacy: Own Unit

OAR411-004-0020(2)(d)

(d) Each individual has privacy in his or her own unit.

Concerns were identified and the facility was provided with technical assistance in the following area:

H 1518 - Individual Door Locks: Key Access

OAR411-004-0020(2)(e)

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit