The findings of the re-licensure survey conducted 03/25/24 through 03/27/24 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 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 03/27/24, conducted 08/13/24 through 08/14/24, 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 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

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 second revisit to the re-licensure survey of 03/27/24, conducted 10/10/24, 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 and interview, it was determined the facility failed to ensure a resident's right to receive services in a manner that protected privacy and dignity for 1 of 1 unsampled resident who received ADL care. Findings include, but are not limited to:

An observation conducted at 12:12 pm on 03/26/24 revealed the following:

Staff 9 (CG) entered Room 1 and stated to the unsampled resident that it was time to go to lunch. Staff 9 then stated, "You're wet. I need to change you." He proceeded to provide incontinent care for the unsampled resident while the door to the resident's room was open and the care provided was in view of the hallway.

The need to ensure residents had the right to receive services in a manner that protected privacy and dignity was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All staff training will be conducted on 4/4/2024 to re-educate staff regarding resident rights and to ensure services are provided in a manner that protects privacy and dignity.

2. The resident care coordinator and executive director will conduct weekly observation checks with staff while providing care to residents.

3. Weekly

4. Resident Care Coordinator and Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs, were readily available to staff, and provided clear direction to staff regarding the delivery of services for 3 of 4 sampled residents (#s 1, 2, and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 01/2024 with diagnoses that included ataxic gait and chronic pain.

The service plan available to staff was dated 01/09/24.

Resident 4 was out of the facility between 01/20/24 and 3/11/24. The resident returned to the facility with several changes including:

* Smoker;

* Fall risk;

* Safety checks two times per shift;

* Pain in right shoulder, neck; and

* Non-pharmalogical interventions for pain: rest, ice pack, PRN medication.

A review of the resident's clinical record showed the most current service plan was dated 03/11/24. The service plan was not available to direct care staff for review.

The need to ensure service plans were available to care staff was discussed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (Resident Care Director) on 03/27/24. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's Disease. The resident's current service plan dated 01/25/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas:

* Supportive devices including use of four-wheeled walker and wheelchair;

* Ambulation status;

* Transfer status;

* Evacuation assistance;

* Activities;

* Use of glasses/vision status;

* Grooming assistance; and

* Toileting assistance.

The need to ensure service plans were reflective of residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

3. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia. The resident's current service plan dated 02/23/24 and temporary service plans were reviewed, interviews were conducted, and observations were made. The service plan was not reflective of the resident's needs and preferences in the following areas:

* Communication status;

* Fall history; and

* Use of a catheter.

The need to ensure service plans reflected residents' needs and preferences was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All service plans will be made available to care staff when a resident experiences a change in condition.

2. All service plans will be reviewed and updated to reflect the resident's care needs.

3. All service plans will be reviewed for accuracy by 5/31/2024 and will continue to be reviewed on a monthly basis.

4. Resident Care Coordinator and Executive Director

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for multiple sampled and unsampled residents during ADL care and meal service. Findings include, but are not limited to:

Observations made from 03/25/24 to 03/26/24 revealed the following:

1. Observations of lunch service on 03/25/24 and 03/26/24 revealed multiple universal caregivers served food and provided direct feeding to residents without donning a protective barrier over potentially contaminated clothing.

2. Staff 9 (CG) and Staff 15 (CG) were observed at 12:00 pm on 03/26/24. Staff 15 entered Room 8 wearing single use gloves, assisted the resident with transferring, then exited the room. She did not remove the gloves or perform hand hygiene after leaving the room. Staff 9 and Staff 15 entered Room 4 wearing single use gloves and assisted the resident with repositioning in bed. They exited the room, doffed the single use gloves, and donned clean gloves without performing hand hygiene. They both began serving residents and carrying food from the kitchen pass to dining room tables.

3. Staff 9 was observed providing incontinent care to an unsampled resident at 12:12 pm on 03/26/24. He entered the room wearing single use gloves and began assisting the resident with a brief change. He changed the soiled briefs and pants, then donned cleaned briefs and pants without removing soiled gloves and performing hand hygiene first. He then exited the room wearing the soiled gloves, removed them in the dining room, and donned new gloves without performing hand hygiene. He then began serving food to residents in the dining room.

4. Staff 11 (CG) was observed walking out of a resident's room with incontinent trash at 12:39 pm on 03/26/24. She disposed of the trash, doffed soiled gloves, and walked into another resident's room without performing hand hygiene.

The need to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. All staff training will be conducted on 4/4/2024 regarding infection prevention and control to ensure a safe, sanitary, and comfortable environment.

2. The Resident Care Coordinator will conduct weekly skill check observations on staff to ensure compliance with our infection prevention control policy and correct processes to prevent cross-contamination and infections among residents and staff.

3. Weekly

4. Executive Director & Residential Coordinator

Based on observation and interview, it was determined the facility failed to maintain effective infection prevention and control protocols to provide a safe, sanitary and comfortable environment for multiple sampled and unsampled residents. This is a repeat citation. Findings include, but are not limited to:

Observations made from 08/13/24 to 08/14/24 revealed the following:

a. Observations of lunch service on 08/13/24 revealed multiple universal caregivers served food to residents without donning a protective barrier over potentially contaminated clothing, and delivered meals to unsampled residents in their rooms without covering the food to prevent potential contamination.

b. Staff 18 (CG) was observed walking out of a resident's room with incontinent trash and single use gloves at 2:22 pm on 08/14/24. She was observed touching multiple surfaces with the soiled gloves. She disposed of the trash, doffed soiled gloves, and walked into another resident's room and assisting the resident with transferring without performing hand hygiene.

The need to maintain effective infection prevention and control protocols was discussed with Staff 17 (Owner) at 9:15 am on 08/14/24. He acknowledged the findings.

1.All staff training will be conducted on 8/21/2024 regarding infection prevention and control to ensure a safe, sanitary, and comfortable environment.

2.The RCC and RSD will conduct weekly skill check observations on staff to ensure compliance with our infection prevention control policy and correct processes to prevent cross-contamination and infections among residents and staff.

3.The RCC ,RSD and Executive Director must oversee the implementation and effectiveness of these infection prevention measures.

Based on observation, interview, and record review, it was determined the facility failed to carry out treatment orders as prescribed for 1 of 1 sampled resident (#2) who had diet orders. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease and was identified during the acuity interview as receiving hospice services. The resident's service plan dated 01/25/24, temporary service plans, and physician orders dated 10/25/23 and 02/27/24 were reviewed, observations were made, and interviews were conducted. The following was identified:

a. The resident had a physician order for a pureed diet. The International Dysphagia Diet Standardization Initiative (IDDSI) described a pureed diet as a Level 5 diet. It must not contain lumps, and must not be sticky. At 1:00 pm on 03/25/24 and 12:23 pm on 03/26/24, staff were observed to feed the resident. The texture of the food was sticky as evidenced by large portions clinging to the spoon and had visible lumps in it.

b. The resident had a physician order for "[s]tart Thick-It [a product which thickens liquids] - follow package directions until the liquid drink is nectar thick in consistency." Observations made on 03/25/24 and 03/26/24 revealed staff provided the resident with non-thickened ice water from the kitchen tap on multiple occasions. No staff were observed thickening the resident's liquids as instructed on the order.

The need to ensure treatment orders were carried out as prescribed was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. Staff will follow physician orders and check each resident's medicine and nutrition.

2. Every new order will be reviewed daily by RN and RCC, who will make any necessary modifications.

3. This will be completed every day and whenever a new order is received.

4. Registered Nurse, Coordinator of Resident Care, and Executive Director

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and contained reasons for use, for 3 of 4 sampled residents (#s 1, 2, and 3) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 3's 03/01/24 through 03/25/24 MAR was reviewed and identified 12 medications that lacked a reason for use.

In an interview on 03/26/24, Staff 6 (MT) stated she did not know why the pharmacy sent the prescriptions over without a reason for use.

In an interview with Staff 1 (ED) on 03/27/24, discussed that facility RN can also add reasons for use to MAR.

The need to ensure accurate MARs included reasons for use was discussed with Staff 1, Staff 2 (RN), and Staff 3 (Residential Care Director) on 03/27/24. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including Lewy body dementia.

The resident's 03/01/24 to 03/25/24 MARs and physician orders dated 03/19/24 were reviewed. Eight medications lacked a reason for use.

The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

3. Resident 2 was admitted to the facility in 10/2023 with diagnoses including Parkinson's disease. The residents 03/01/24 to 03/25/24 MAR and physicians orders dated 12/29/23 were reviewed. Six medications lacked a reason for use.

The need to ensure an accurate MAR that included minimum requirements was discussed with Staff 1 (Executive Director) and Staff 2 (RN) on 03/27/24. They acknowledged the findings.

1. Each prescription has a purpose for being used, and these purposes will all be reviewed by May 31, 2024.

2. The daily medication reviews by the RN and RCC will ensure that medication changes, if any, will be updated and diagnosis has been added

3. With every new prescription, this will be carried out every day.

4. ED, RCC, & RN   

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled staff (#s 6 and 14) completed 12 hours of in-service training annually on topics related to the provision of care for persons in a community-based care setting, including six hours on dementia care and the annual infection control training. Findings include, but are not limited to:

Staff training records were reviewed on 03/26/24. Staff 6 (MT), hired 11/20/20, and Staff 14 (CG), hired 11/16/21, lacked documentation of completing annual infection control training and six hours of annual dementia care in-service training in the most recent calendar year.

In an interview on 03/26/24, Staff 1 (ED) stated Staff 6 and Staff 14 had attended monthly staff meetings with training topics but acknowledged all the annual training had not been completed.

On 03/26/24, the need to ensure all direct care staff completed 12 hours of annual required training, including six hours on dementia care and annual infection control training, was discussed with Staff 1. She acknowledged the findings.

1.All staff members must complete 12 hours of annual training, which consists of 2 hours on infection control and 6 hours on dementia care. All staff members must also record their attendance at monthly inservices.

2. Staff will receive reminder notes from the office manager to finish their training as needed.

3. The office manager will update the employees on whether they need to attend classes by reviewing personnel files twice a month.

4.Executive Director and Office Manager 4.

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

Fire drill records dated 10/2023 to 03/2024 were reviewed with Staff 1 (Executive Director) at 1:37 pm on 03/26/24. There was no documented evidence the facility was completing the following:

* Conducting unannounced fire drills every other month; and

* Keeping a written record of the number of occupants evacuated, time to evacuate, and problems encountered relating to residents who resisted or failed to participate in fire drills.

During the record review, Staff 1 stated the facility was conducting fire drills every three months, and they were not evacuating any residents during the drills.

The need to ensure the facility conducted fire drills according to Oregon Fire Code was discussed with Staff 1 on 03/27/24. She acknowledged the findings.

1. Fire Drill is being held every other month and resident evacuation plan.

2. Fire drills will follow the process now listed on the new Fire & Life Safety forms.

3. Fire & Life safety will be visted as needed to ensure community compliance.

4. Executive Director & Maintenance Director

Based on interview and record review, it was determined the facility failed to ensure annual reinstruction of fire and life safety procedures to residents according to Oregon Fire Code. Findings include, but are not limited to:

During an interview at 1:44 pm on 03/26/24, Staff 1 (Executive Director) stated the facility had not developed a system to complete annual reinstruction to residents regarding the facility's fire and life safety procedures. Therefore, there was no documentation to review.

The need to ensure documentation of annual reinstruction of the facility's fire and life safety procedures to residents was discussed with Staff 1 on 03/27/24. She acknowledged the findings.

1. The resident and their family will consider fire and life safety training at the next care plan meeting. The resident care plan will include information about and documentation of the teaching and training of alternate escape routes.

2. The care plan, which will be reviewed, will be updated with the new Fire and Life Safety checklist.

3. Quarterly

4. Executive Director

Based on interview and record review, it was determined the facility failed to ensure annual re-instruction of fire and life safety procedures to residents according to Oregon Fire Code. This is a repeat citation. Findings include, but are not limited to:

On 08/13/24 at 2:08 pm, Staff 16 (Office Manager) stated there was a system discussed for the annual re-instruction of fire and life safety procedures to residents, but there was no documentation that a system had been implemented.

On 08/14/24 at 11:06 am, Staff 17 (Owner) and Staff 3 (Residential Care Director) confirmed the lack of documentation of annual re-instruction of fire and life safety procedures to residents.

The need to ensure documentation of annual re-instruction of the facility's fire and life safety procedures to residents was discussed with Staff 17 and Staff 3 on 08/14/24. They acknowledged the findings.

1. The fire and life safety training has been added to care plan meeting. The resident care plan will include information about and documentation of the teaching and training of alternate escape routes.

2. The care plan, which will be reviewed, will be updated with the new Fire and Life Safety checklist.

3. Quarterly

4. Executive Director.

Based on observation, interview, and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C295, C422, C513, and C530.

Refer to C 240

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

The facility was toured at 10:15 am on 3/25/24. Observations revealed bleach and other chemical cleaners in unlocked storage in the following areas:

* Cottage 'A' laundry room; and

* Cottage 'B' basement kitchenette under the sink.

The need to ensure locked storage for chemicals and other toxic materials was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1. All hazardous and chemical materials will be kept locked in the storage area.

2. The Executive Director and Maintenance Director will walk the laundry rooms and under the kitchenette sink once a week to look for any stored things.

3. Each week, this will be completed.

4. Executive Director, Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. Findings include, but are not limited to:

The interiors of Cottage 'A' and Cottage 'B' were toured at 10:15 am on 03/25/24. The following was identified:

1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, ceiling fans, vents, ledges, and baseboards.

2. In Cottage 'A,' the following was observed:

* An unpleasant odor in the hall near Rooms 3 and 4 that did not dissipate;

* The couch in the activities area was badly stained;

* A wood arm chair in the activities area had a broken arm;

* A lounge chair outside of Room 6 was badly stained;

* The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage;

* The carpet in the hall of the laundry room had large stains; and

* The bottom ledge in the shower room across from the laundry room was peeling away from the floor.

3. In Cottage 'B,' the following was observed:

* The main entrance door was rusted on the inside and the outside;

* The interior door frame of the main entrance door was chipped on both sides on the bottom;

* The laundry room had a strong mildew odor that did not dissipate;

* The bathmat in the basement shower room was worn with black matter around the edges;

* The shower rod in the basement shower room was rusted;

* There was an inch-wide crack between the basement shower room floor and the hall floor; and

* There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey.

The need to ensure the facility was maintained clean and in good repair and free from unpleasant odors was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1. The staff cleaning task has been revised, and the maintenance director will now follow the new carpet cleaning timetable.

2. By May 31, 2024, every location that requires attention will be cleaned, and a weekly spot check will be conducted on every area.

3. Daily & Weekly

4. Executive Director ,Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was maintained in clean and good repair and free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 08/13/24 at 9:45 am. The following was identified:

1. Facility-wide, there was a buildup of dust, dirt, splashes, stains, and black scuffs on the walls, doors, door frames, vents, ledges, and baseboards.

2. In Cottage 'A,' the following was observed:

* The couch in the activities area was stained and torn;

* The baseboards in the laundry room and the door frame in the shower room across from the laundry room were warped with water damage; and

* The carpet throughout the building was stained.

3. In Cottage 'B,' the following was observed:

* The main entrance door was rusted on the inside and the outside;

* The interior door frame of the main entrance door was chipped on both sides on the bottom;

* The white couch in the sun room had stains on the front, seat, and arms; and

* There was an unpleasant odor in the hall outside of Room 12 in the basement that did not dissipate during the survey.

The building was toured with Staff 17 (Owner) and the areas needing cleaning and repair as well the area with unpleasant odors were reviewed. He acknowledged the findings.

1. The maintenance director is going to follow to the updated carpet cleaning schedule, and the staff cleaning duty has been updated to include the rail, walls, and doors. We are going to order some new furniture. We have plans to order a new door for cottage B.

2.  Every location that requires attention will be cleaned, and a weekly spot check will be conducted on every area.

3. Every week

4. Executive Director ,Maintenance Director,Housekeeper

Based on interview and record review, it was determined the facility failed to ensure soiled linens and soiled clothing were washed with a minimum rinse temperature of 140 degrees Fahrenheit or a chemical disinfectant. Findings include, but are not limited to:

The facility's March temperature logs were reviewed at 2:00 pm on 03/26/24. The logs indicated the facility washing machines rinse temperatures ranged from 115 to 118 degrees Fahrenheit. During an interview at 2:14 pm on 03/26/24, Staff 16 (Office Manager) confirmed the facility was not using a detergent that contained disinfectant for soiled laundry.

The need to ensure a minimum rinse temperature of 140 degrees Fahrenheit or use of a chemical disinfectant for soiled linen and clothing was discussed with Staff 1 (Executive Director) on 03/27/24. She acknowledged the findings.

1.Disinfectant detergent will be used to clean all soiled clothes and linens.

2.There will always be a disinfecting detergent on hand to clean up soiled laundry.

3. Every day.

4. Staff that provide direct care, Housekeeping, and Executive Director

Based on observation and interview, it was determined the facility failed to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. This is a repeat citation. Findings include, but are not limited to:

Observations of the Cottage B laundry room and janitorial closet were made at 11:54 am on 08/13/24. The washing machine did not have a temperature gauge to ensure a rinse temperature of 140 degrees Fahrenheit. There was no disinfectant observed in either the laundry room or the closet.

During an interview at 11:55 am on 08/13/24, Staff 18 (CG) stated she used one detergent for all laundry. The detergent did not contain a disinfectant. During an interview at 12:05 pm on 08/13/24, Staff 13 also confirmed she used one detergent for all laundry that did not contain a disinfectant.

The need to ensure to ensure washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used was discussed with Staff 17 (Owner) at 9:43 am on 08/14/24. He acknowledged the findings.

1.Disinfectant detergent will be used to clean all soiled clothes.

2.There will always be a disinfecting detergent on hand to clean up soiled laundry.

3. Every day.

4. Staff that provide direct care, Housekeeping, and Executive Director