The findings of the re-licensure survey conducted 06/06/22 through 06/08/22 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

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 first revisit to the re-licensure survey of 06/08/2022, conducted 08/22/2022 through 08/24/2022, 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 interview and record review, it was determined the facility failed to ensure investigations of incidents were thorough and complete and incidents of suspected abuse or neglect were reported to the local SPD office in a timely manner for 1 of 1 sampled resident (#2) reviewed with an altercation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 09/2014 with diagnoses including vascular dementia and chronic kidney disease.

On 05/11/22 staff documented another resident approached Resident 2 and "took the flowers on the table from Resident 2 and Resident 2 slapped at their hand and told them no".  

The incident of a resident to resident altercation required a documented investigation to rule out neglect of care or abuse.

On 06/08/22, the survey team requested the incident investigation, and was provided a form dated 05/11/22 labeled "Resident to Resident - Staff Questionnaire".

The Resident to Resident staff questionnaire failed to document:

* The time the incident occurred;

* The names of staff that were present;

* Follow-up actions to protect the residents;

* Plan to prevent reoccurrence:

* Determination if abuse or neglect had been ruled out; and

* Administrator review and signature.

The incident had not been reported to the local SPD.

On 06/08/22 the survey team discussed the incomplete investigation with Staff 2 (RN), and requested the facility report the resident to resident altercation to the local SPD. A fax confirmation of the report was received prior to survey exit.

The need to ensure any resident to resident altercations were immediately investigated to rule out abuse or neglect, documented completely, and reported if necessary was discussed with Staff 2 (RN) on 06/08/22. She acknowledged the findings.

Resident #2 encounter with another resident has been investigated and found to be isolated in nature, related to mis-understanding about the flowers and both resident's dementia.

Staff Education will be provided at next department meeting 6/27/2022.  This will include:

oDefinitions of resident to resident altercations and reporting of any incidents observered/action taken.

oEducation on implementation of Resident to Resident Event evaluatation within electronical record PCC

oNotifying RN/Admin immediately following incident

oAdministrator and RN to ensure policy in place for complete and timely investigations, to rule out abuse.

Facility Admin to audit weekly X 4 and then monthly ongoing for required documentation and questionnaire forms by staff indicating possible resident to resident altercations, audits will be completed monthly ongoing to ensure compliance.  

Facility RN and Facility Administrator to assure incidents are sufficiently investigated and documented and reported to APD for any findings of abuse, per regulation.  

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:

On 6/6/22 at 9:15 am, the main kitchen was observed to need cleaning and repair in the following areas:

* Entrance and exit door to the kitchen had chipped  paint, gouges and dirt and debris on them;

* Grease build-up and food debris was observed on  stainless steel knobs on the steam table and stove, stove front, sides and top, and floor by the stove;

* The Cupboard underneath the steam table was missing the front laminate, exposing wood underneath and had cracks in it; and

* The window where clean dishes were stored had paint peeling off.

On 6/6/21 at 10:21 am, the surveyor toured the areas that needed to be clean and repaired with Staff 4 (Dietary Manager) and Staff 5 (Maintenance Director).  They acknowledged the areas that needed to be cleaned and repaired.

Kitchen Repairs Completed:

- Chipped Paint on Door Repainted

- Grease build up on knobs cleaned: Stove knobs and surrounding area specifically added to the weekly deep clean routine

- Exposed wood filled and sealed with paint

- Peeling Paint removed and repainted

Maintenance department to have repairs completed by August 7th 2022.

Maintenance Director and Dietary Manager to audit weekly X 4 weeks, then Monthly X 90 days and then quarterly thereafter to ensure on going compliance with  kitchen conditions and repair as needed.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had significant changes of condition were evaluated, monitored or referred to the RN for 1 of 1 sampled resident (# 2) who experienced a significant change of condition.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2014 with diagnosis including vascular dementia and kidney disease.

The most recent service plan (dated 04/22/22) noted Resident 1 required pureed food texture and required a staff person to actively assist with eating.

Weight records identified the resident had a significant loss between 02/16/22 (90 lbs.) and 03/17/22 (81.4 lbs.) s/he lost 8.6 lbs. or a decrease of 9.56% of his/her total body weight in one month.

During the survey, Resident 2 was observed to receive pureed food and meal assistance at two meals, consuming approximately 50-75% of his/her meals.

There was no documented evidence Resident 1's significant weight loss had been evaluated, referred to the facility nurse, and the service plan updated to reflect the change of condition.  

The facility's failure to report a resident's significant change of condition to the RN for assessment was discussed with Staff 2 (RN) on 06/08/22. She acknowledged the findings.

Resident #2 weight loss has been assessed by RN, updates to interventions and service plan implemented as indicated.

100% review of all current residents has been completed to identify any other resident with significant weigh loss, RN assessment completed as indicated.

RN inserviced on policy for significant change assessments.  Direct care staff will be provided at next department meeting 6/27/2022.  This will include:

- When and how to report weight loss

- Who to report weight loss too

Health Services Director to review and monitor documented weights weekly ongoing, ensuring any resident with significant weight loss is assessed, monitored to ensure ongoing compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by an RN for 1 of 1 sampled resident (#2) who experienced significant weight loss.  Findings include, but are not limited to:

Resident 1 was admitted to the facility in 09/2014 with diagnosis including vascular dementia and kidney disease.

Weight records identified the resident had a significant loss between 02/16/22 (90 lbs.) and 03/17/22 (81.4 lbs.) s/he lost 8.6 lbs. or a decrease of 9.56% of his/her total body weight in one month.

There was no evidence the facility RN had completed a significant change of condition assessment to include documented findings, resident status, and interventions made as a result of the assessment.

The need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 2 (RN) on 06/08/22 . She acknowledged the findings.

Refer to C270.

See also C270

Resident #2 significant weightloss has been assessed, interventions and service planning updated as indicated.

Facility RN to review all current residents experiencing a significant change of condition to ensure required documentation is updated and accurate.

Facility RN will utilize "Change of Condition" assessment chart note template to ensure all areas are covered and easily identified.

In our facility weekly resident review, resident conditions to be reviewed by department head staff to ensure all residents experiencing a change of condition are addressed and appropriately documented.

Health Services Director to review and monitor documented weights weekly ongoing, ensuring any resident with significant weight loss is assessed, monitored to ensure ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to providing services to residents for 2 of 3 newly hired staff (#s 8 and 11) whose training records were reviewed. Findings include, but are not limited to:

Facility training records for Staff 8 (CG), hired on 04/04/22, and Staff 11(CG), re-hired on 04/19/22, were requested on 06/07/22 at 10:25 am. The following were revealed:

a.  The facility lacked documented evidence  Staff 11 completed all required pre-service training and pre-service orientation with all required elements prior to beginning her job duties including:

* Resident rights and the values of community based care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

* Written job description; and

* Pre-service dementia training.

b.  The facility lacked documented evidence Staff 8 completed all required pre-service training and pre-service orientation with all required elements prior to beginning her job duties including:

* Resident rights and the values of community based care;

* Abuse reporting requirements;

* Standard precautions for infection control;

* Fire safety and emergency procedures;

* Written job description; and

* Pre-service dementia training.

The need to ensure newly hired staff completed pre-service training with all required elements prior to beginning their job duties was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/08/22. They acknowledged the findings.

Staff member #8 and #11 have received all required Pre-service training.

Complete review of all Employee files to ensure all information present and complete.  All files to be up to date with required staffing requirements and trainings by 8/7/2022

Pre-Service training to be completed per policy, using Oregon Care Partners elearning resources and facility direct training, to include all required elements.  

Staffing Director and Administrator to audit monthly ongoing and ensure trainings completed with all new hires.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 11) demonstrated satisfactory performance in any assigned duty within 30 days of hire. Findings include, but are not limited to:

Facility training records for Staff 8 (CG), hired on 04/04/22, and Staff 11(CG) re-hired on 04/19/22 were requested on 06/07/22 at 10:25 am. The following were revealed:

a.  The facility lacked documented evidence Staff 11 demonstrated satisfactory performance in the following required areas within 30 days of re-hire including:

* Role of service plans in providing individualized care;

* Changes associated with normal aging;

* Identification, documentation and reporting;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* First aid/abdominal thrust.

b.  The facility lacked documented evidence Staff 8 demonstrated satisfactory performance in the following required areas within 30 days of hire including:

* Role of service plans in providing individualized care;

* Changes associated with normal aging:

* Identification, documentation and reporting;

* Conditions that require assessment, treatment, observation and reporting;

* General food safety, serving and sanitation; and

* First aid/abdominal thrust.

The need to ensure newly hired staff demonstrated satisfactory performance in any duty they were assigned within 30 days of hire was reviewed with Staff 1 (Administrator) and Staff 2  (Director of Health Services) on 06/08/22. They acknowledged the findings.

Staff member #8 and #11 have received required 30 day training.

All Employees files be reviewed to ensure they have been evaluated for competencies in any duties they are assigned. All Employee charts will be reviewed for completeness by 8/7/2022

During employee training process care staff will be provided the 30 day orientation template, with additional elearning and skills competencies. The Training checklist will be turned into the staffing coordinator within the first 30 days of employment.

First Aid Training will be provided during Preservice Training.

Staffing director and Administrator to audit monthly ongoing all new hires to ensure 30 day training is complete, per requirments.

Based on interview and record review, it was determined the facility failed to ensure documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 3 of 3 long-term staff (#s 5, 9 and 12) whose training records were reviewed.  Findings include, but are not limited to:

Annual in-service training records for Staff 5 (CG), hired on 05/24/18, Staff 9 (CG), hired on 03/25/13 and Staff 12 (MT), hired on 03/04/14 were requested on 06/07/22 at 10:25 am, 1:17 pm and 3:15 pm and on 06/08/22 at 10:25 am. The records were not received prior to the end of the record review process as requested.

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 1 (Administrator) and Staff 2 (Health Services Director) on 06/08/22. They acknowledged the findings.

Employee #5,  9 and 12 have received required annual inservicing hours

Review of all Employee files to ensure all staff on track to have completed the accurate number of inservices hours within the year of their anniversary.

All Annual training hours provided to all staff within facility.

Staff will be inserviced on the requirements to attend facility inservices, to ensure completion of requirements.

Administrator inserviced Staffing director on updating staff files to reflect completion of inservices attended/completed.   

Staff Coordinator will manage documentation for Care Staff Training Records for required trainings and  inservices. Administrator and Staffing Coordinator will audit monthly X 90 days then quarterly thereafter to ensure ongoing compliance.

All Records to be updated and easily accesible in employee files by 8/22/2022

Based on interview and record review, it was determined the facility failed to document all required components of fire drills and failed to provide fire and life safety instruction to staff on alternate months of fire drills. Findings include, but are not limited to:

Fire drill records from 12/2021 through 06/2022 were reviewed on 06/07/22. The facility lacked documented evidence fire drills included the following required components:

* The escape route used;

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

* Number of occupants evacuated.

The need to ensure all required components of fire drills were documented was discussed with Staff 5 (Maintenance Director) on 06/07/22 and Staff 1 (Administrator) on 06/08/22. They acknowledged the findings.

Facility has updated Fire Drill Records to prompt for all required elements. Updates in effect immediately.

All Staff have been inserviced as required by rule, including but not limited to;

Additions Include:

- Escape Route Used

- Problems Encountered and comments relating to residents who resisted or failed to participate in the drills

- Number of occupants evacuated

Administrator will complete monthly audits X 90 days and then quarterly thereafter, to ensure ongoing compliance.

Maintenance Director to ensure all required components are documented with each fire drill. Every other month.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept in good repair. Findings include, but are not limited to:

Observations of the facility on 06/06/22 revealed the following:

* Elevator doors had scratched and chipped paint;

* Doors and door frames, including but not limited to Room 212, 213 and 238, were damaged; and

* Carpet with dark stains throughout dining room, first floor hall, second floor hall, and common areas.

During an interview on 06/07/22 Staff 5 (Maintenance Director) acknowledged the findings.

- Elevator paint repaired

- Doors and Door Frames Repaired and painted

- Carpet Stains cleaned and removed

Repairs completed by 8/7/2022

Staff education to be provided at staff meeting 6/27/2022

- Remind staff to report anything in need of repair or cleaning

- Ensure all staff know how to report these issues

Added doors and elevator condition to maintenance staffs quarterly repair check.

All Facility staff to report repairs needed immedatly to Maintenance department.

Common Area carpet cleaning increased to a monthly rotation by Maintenance Department.