The findings of the initial survey conducted 09/07/22 through 09/08/22 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, 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 to the initial survey of 09/08/22, conducted on 12/14/22, 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 implement effective methods of infection control. Findings include, but are not limited to:

Observations were made in the MCC during the survey to determine adherence to universal precautions for infection control.

On 09/08/22 at 11:20 am, the surveyor observed a CG assist Resident 4 in the bathroom. The CG had on a pair of gloves while providing care to the resident. After the incontinent care was provided to the resident, the CG touched the resident's wheelchair handles with soiled gloves. The CG removed her soiled gloves and attempted to exit the resident's apartment. The surveyor asked the CG to wash her hands before proceeding to another resident's room.

The lack of proper infection control relating to hand hygiene was discussed with Staff 1 (ED) and Staff 5 (RCC) on 09/08/22 at approximately 11:30 am. Staff 5 provided an in-service on hand hygiene to all care staff at that time.

The need to ensure proper infection control was utilized for hand hygiene was discussed with Staff 1, Staff 2 (Owner), Staff 3 (RN), Staff 4 (RN), Staff 5 and Staff 6 (RCC) on 09/08/22. They acknowledged the findings.

1.) Re-training in infection control/Hand hygiene with demo with all employees with Health Service Dirctor. Issued a Personal Improvement Plan to the employee in example.

2.) Every Current Employee should have the infection Control class done and Hand hygiene with Health Service Director, if they are a new employee they should have there infection control class done prior to 1st day on floor.

3.) Staffing director to confirm each employee has infection control class completed before going on floor and HSD has signed off on infection control compentencey.

4.) Executive Director will final review new employees packets and training documents and compentences at end of each month.

Based on observation, interview and record review, it was determined the facility failed to ensure proper food preparation and food service was implemented in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

During the kitchen tour on 09/07/22, the following areas were found to be deficient:

* Proper thawing of frozen raw meats;

* Proper cooling methods;

* Availability of pasteurized eggs for soft cooked entrees; and

* Cold foods maintained at or below 41 degrees F. when served from the tray line.

The need to ensure proper food preparation and food service was implemented was discussed with Staff 1(ED) and Staff 2 (Owner) on 09/08/22. They acknowledged the findings.

1.) Re-training on proper food preparation, which includes proper thawing of frozen foods with pull method, proper cooling methods with the purchase of a  ice wand, and maintaining cold foods below 41 degrees F by keeping cold food in fridge untill ready to be served. And purchased pasteurized eggs for soft cooked entrees.

2.) Staff having the proper knowledge for proper food preparation and the tools to help keep the food within proper tempature and following regulations.

3.) Daily audit will be done by the Kitchen Manager and ensuring that the right tools are being used.

4.) Executive Director to monitor the temp books from kitchen and doing meal monitoring in the kitchen once a 2-3 times a week.

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

1. Resident 2 was admitted to the facility in 07/2022 with diagnoses including Alzheimer's disease.

The resident's 08/09/22 service plan, temporary service plans and progress notes dated 07/11/22 through 09/06/22 were reviewed. The resident was observed throughout the survey and staff were interviewed. The service plan was either not reflective of the resident's current needs or lacked clear caregiving instruction in the following areas:

* Activities;

* Bathing and assistance needed;

* Safety checks and how staff would know when the resident was in his/her room; and

* Behavior interventions.

The need to ensure the resident's service plan was reflective of the resident's needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Owner), Staff 3 (RN), Staff 4 (RN), Staff 5 (RCC) and Staff 6 (RCC) on 09/08/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including unspecified dementia with behavioral disturbance and depression.

a. The resident's 08/27/22 service plan, temporary service plans and progress notes dated 06/08/22 through 09/07/22 were reviewed. The resident was observed throughout the survey and staff were interviewed. The service plan was either not reflective of the resident's current needs or lacked clear caregiving instruction in the following areas:

* Activities;

* Skin care provided by staff; and

* Behavior interventions specific to crying.

b. On 09/07/22 during the acuity interview, Resident 4 was identified as needing his/her liquids thickened. The resident's service plan was reflective of the need for thickened liquids. On 09/08/22 at 11:35 am, Staff 12 (Activities Coordinator) was observed to give the resident un-thickened water and assist him/her to drink the water. There was no negative outcome observed at that time.

The need to ensure the resident's service plan was reflective of the resident's needs, provided clear direction to staff and was being followed was discussed with Staff 1 (ED), Staff 2 (Owner), Staff 3 (RN), Staff 4 (RN), Staff 5 (RCC) and Staff 6 (RCC) on 09/08/22. They acknowledged the findings.

1.) Detailed caregiving instructions will be audited. Adl needs and level to be reviewed by both RCC's and shower schedule to be updated as needed.

2.) HSD and RCC's will interview family and residents at time of admission for more of a personal directed service plan and instructions this will help get more person centered service plan.

3.) All service plans will be updated by the AOC date of 10/31/221. With every new admit, updated SP or if RCC's/HSD notices a COC in adl abilities.

4.) Executive Director to do final review of service plans and TSP's as soon as they are published and sign off.

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 160 and C 240.

Refer to C160 and C240 POC

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled newly-hired direct care staff (#s 5, 10, 18 and 19 ) completed all required orientation and pre-service dementia training; 1 of 1 new hired direct care staff (# 10) completed all areas of competency training within 30-days of hire and 3 of 4 long term direct care staff (#s 16, 20 and 22 ) 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 were reviewed with Staff 7 (Human Resources) on 09/08/22. The following deficiencies were identified:

1. Staff 5 (CG/RCC) was hired on 08/16/21.

a. The following pre-service training requirements were not met prior to providing care and services independently:

* Use of supportive devices with restraining qualities prior to beginning job duties.

2. Staff 18 (CG) was hired on 08/10/22.

a. The following orientation and pre-service training was not completed prior to beginning job duties:

* Infectious disease prevention.

b. Staff 18 failed to complete pre-service dementia training, including the use of supportive devices prior to providing care and services independently.

3. Staff 19 (CG) was hired on 08/25/22.

a. The following orientation and pre-service training was not completed prior to beginning job duties:

* Infectious disease prevention.

b. Staff 19 failed to complete pre-service dementia training, including the use of supportive devices prior to providing care and services independently.

4. Staff 10 (MT) was hired on 05/02/22.

a. The following pre-service training requirements were not met prior to providing care and services independently:

* Use of supportive devices with restraining qualities prior to beginning job duties.

b. Demonstrated competency in the following training areas were not completed within 30-days of hire:

* Role of the service plans in providing individual care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting on changes of condition;

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

* General food safety, serving and sanitation.

5. Long term direct care staff, Staff 20 (CG), hired on 07/21/21, Staff 16 (CG) hired on 08/18/21, Staff 22 (CG) hired on 08/27/21 lacked 16 hours of annual in-service training, including 6 hours of dementia care topics.

The need to ensure newly hired direct care staff completed all orientation training prior to beginning any job duties, pre-service training prior to working independently, and that long term direct care staff completed 16 hours of in-service training annually, including six hours of annual dementia care training, was reviewed with Staff 1 (ED) Staff 2 (Owner) and Staff 7 on 09/08/22 . They acknowledged the findings.

1.) Training Documents to be up to date competency training should be done within 30 days and pre-service training and infection control should be done prior to independently working with cares and services

2.) Having and providing the proper training that is up to regulations and consistancey will have this system corrected.

3.)Staffing Director/HR will maintain hire and gather the correct training documentation prior to hiring and on going training records. Health service Director with sign off on compentencys for Med techs. Staffing director to sign off on compentecncys for all other employees.

4.) Executive Director will review training documents once a month and for every new hire.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260.

Refer to C260 POC

Based on interview and record review, it was determined the facility failed to ensure an individualized activity plan was developed and updated for each resident, based on their activity evaluation for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 3 and 4's most recent evaluations and service plans were reviewed. The completed activity evaluations were not readily available to staff, and the activity plans lacked specific instructions regarding what, when, how, and how often staff were to provide support and assistance to residents with individualized activities.  

On 09/08/22 the need to develop personalized activity plans that were reflective of each resident's evaluation was discussed with Staff 1 (ED), Staff 2 (Owner) and Staff 5 (RCC). They acknowledged the findings.

1.) Review and edit activity plans for each residents that are personalized to activities they currently are in to and when to do them, how, and with individual activities. Activity director implemented activity list binder of preffered activities per each resident likes and dislikes. And will be actively invovled with the Activity section of the service plan.

2.) HSD and Rcc's will use activity list binder to update service plans when it comes to daily activities to help have more of a personalized activity plan.

3.) All service plans will be updated by the compliance date of 10/31/22. After all service plans are updated, this will need to be evaluated with every new admit, re-admit, needing updated SP or if RCC's/HSD notices a COC in ADL abilities.

4.) Executive Director to do final review of service plans and TSP's as soon as they are published.