The findings of the re-licensure survey, conducted 05/16/22 through 05/17/22, 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 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 first re-visit of the re-licensure survey of 05/17/22, conducted 09/20/22 through 09/22/22, 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 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 second revisit to the re-licensure survey of 05/17/22, conducted 12/15/22 through 12/16/22, 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 the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 05/16/22 at 10:30 a.m., the facility's main kitchen was observed to need cleaning or repair in the following areas:

* Floors throughout the kitchen, including dry storage and walk-in refrigerator and freezer, had black matter build-up and food debris in corners, around perimeter edges, under equipment, and inside floor drains;

* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, white/gray accumulation, dust, and/or debris;

* Water was pooled around the feet of the ice machine and spreading down the floor;

* Ceiling vents had an accumulation of lint and dust on the grates;

* Debris was noted in the floor drain nearest the steam table;

* Chipped wall edges with missing pieces were noted in multiple areas;

* The fan in the kitchen was covered in dust and cobwebs;

* Exposed knob posts on the stove had thick accumulation of dust and cobwebs;

* Ceiling lights throughout the kitchen had dead insects and debris inside; and

* Doors, door frames, and walls had splatters, spills, and/or chips.

On 05/16/22 the neighborhood kitchens on all three floors were observed to need cleaning or repair in the following areas:

* Debris and spills were noted in drawers and cupboards throughout the neighborhood kitchens;

* Coffee shelves in multiple kitchens had missing laminate, gouged cupboard edges, and exposed particle board;

* Dark accumulation and debris was noted along the edges of the flooring underneath cupboards in multiple areas;

* A large gap in flooring with a piece lifting under the counter was noted in the second floor east kitchen;

* Spills and debris were noted in refrigerators and freezers; and

* A cracked lower door shelf was noted in the third floor refrigerator.

The need to ensure the kitchen and neighborhood kitchens were kept clean and in good repair was shown to and discussed with Staff 1 (Administrator) on 05/16/22. She acknowledged the findings.

1. A thourough deep clean of the kitchen will be conducted to include floors and perimiters throughout kitchen, walk-in refrigerator, dry storage, freezer, underneath and behind appliances and shelving, sinks, vents, lights, floor drains, and fans. Cleaning will be completed by Dietary team and Maintenance Director. All 6 neighborhood kitchens will be deep cleaned and free of debris and dust, to be completed by the Housekeeper. Lifted areas of flooring in neighborhood kitchens will be assessed and repaired by the Maintenance Director along with the cabinets housing coffee machines and cracks to refrigerators.

2. Dietary Director will ensure a cleaning checklist with appropriate tasks are assigned and completed daily by Dietary staff for main kitchen and 6 neighborhood kitchens. Dietary staff will report to Maintenance Director/Administrator if areas are in need of repair/cleaning beyond their abilities.

3.Maintenance Director will complete a sanitation audit for all 7 kitchen areas quarterly. Dietary Director will perform audits of cleaning checklists quarterly.

4. Maintenance Director and Dietary Director will turn in their audits to the Administrator and bring their audits to QAPI quarterly for three consecutive quarters or until the alleged difficient practice resolved.  

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 1 of 1 newly admitted resident (#3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in 02/2022. The resident's move-in evaluation was dated two days after s/he moved into the facility. The following elements were not addressed in the move-in evaluation:

* Customary routines, including sleeping, eating, bathing;

* Interests, hobbies, social, and leisure activities;

* List of current diagnoses;

* Personality, including how the person copes with change or challenging situations;

* Pain: pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort;

* Nutrition habits, fluid preferences, and weight if indicated; and

* Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature.

The need to complete move-in evaluations prior to a resident being admitted to the facility and to address all required elements in each evaluation was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Health Services Coordinator) on 05/17/22. They acknowledged the findings.

1. Resident Services Coordinator will create a new functional assessment addressing customary routines including sleeping, eating, bathing, interests, hobbies, social and leisure activities, list of diagnoses, personality and coping with change or challenging situations, pain including non-pharmaceutical and pharmaceutical interventions, how this resident expresses pain or discomfort, nutrition habits, fluid preferences, weight, and environmental factor which impact this resident's behavior such as noise, lighting and room temperature.

2. RN, Administrator, and Resident Services Coordinator will print off move-in assessment tool from PCC and bring copies when first meeting to evaluate a potential move-in to ensure all information is obtained prior should potential resident be appropriate for move in.

3. Administrator will audit move-in evaluations completed by Resident Services Coordinator each time a new resident moves in, the day before move-in date to ensure evaluation addresses all required elements.

4.Resident Services Coordinator will be responsible to complete corrections. Resident Services Coordinator/Administrator will monitor move-in evaluations prior to resident move-in dates.

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 to staff regarding care and services, and were followed by staff for 2 of 4 sampled residents (#s 1 and 2). Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in May 2018 with diagnoses including end stage dementia.

Observations of the resident, interviews with staff, and review of the service plan dated 02/21/22 showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff, and/or was not followed by staff in the following areas:

* Dressing, toileting, and ambulation;

* Transfers, walker, and wheelchair use;

* Skin risk, pressure reduction, and heel protectors;

* Evacuation ability; and

* Falls and safety interventions.

The need to ensure resident service plans were reflective of current care needs, provided direction to staff, and were followed was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Health Services Coordinator) on 05/17/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 11/2019 with diagnoses which included dementia with behavioral disturbance.

Review of the resident's current service plan, observations of the resident, and interviews with staff revealed the service plan was not reflective of the resident's current status in the following areas:

* Ability to use the call system;

* Involuntary physical movements of the trunk and limbs; and

* How the resident expressed agitation.

Resident 1 was observed to exhibit involuntary movements of his/her trunk and limbs on 05/17/22.

The need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Health Services Coordinator) on 05/17/22. They acknowledged the findings.

1. Resident 2's Service Plan will be updated by Resident Services Coordinator to ensure that service plan is reflective and providing details for staff to carry out care including dressing, toileting, ambulation, transfers, assistive device use, skin risk, pressure reduction, heel protectors, evacuation ability and falls/safety intervetntions. Resident 1's Service plan will also be updated by Resident Services Coordinator to ensure the service plan is reflective and providing details for staff to carry out care including ability to use the call system, involuntary physical movements of the trunk and limbs, and how this resident displays/expresses agitation.

2. RN will ensure significant change of conditions are completed promptly within 24-48 hours. When completed RN will give significant change assessment to Resident Services Coordinator to implement in an updated service plan reflecting updates and details for staff to carry out current care.

3. Administrator or Designee will complete a 10% audit of service plans monthly to ensure they are reflective of residents current care needs. Results of audits will be brought to QAPI meeting.

4. RN will be responsible to see that corrections of Resident 1 and 2's service plans are completed and accurately reflective of current care needs. RN will monitor all service plans for reflective care each time Resident Service Coordinator completes service plan to be reviewed and signed by the RN, recommend updates when needed.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 2 sampled residents (#s 6 and 7).  This is a repeat citation. Findings include, but are not limited to:

1. Resident 6 was admitted to the facility in August 2022 with diagnoses including a recent hip fracture and depression.

Interviews with staff and a review of the service plan, dated 09/09/22 showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Hygiene and grooming needs;

* Meal management and preferences;

* Snacks and hydration preferences;

* Bathing and toileting assistance;

* Bedtime assistance and preferences;

* Activity needs and preferences;

* Precautions related to recent hip fracture and fall interventions; and

* Effective non-drug treatments.

2. Resident 7 was admitted to the facility in June 2022 with diagnoses including a atrial fibrillation and phlebitis.

During the entrance conference, staff reported Resident 7 had recently been "essentially bedbound" related to edema, weeping wounds and leg pain.

Observations, interviews with the resident and staff and a review of the service plan, dated 09/13/22, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Meal management and preferences and when to offer assistance to attend meals in the dining room;

* Snacks and hydration preferences;

* Bathing and toileting assistance, including how often and type of assistance needed, equipment needed;

* Bedtime assistance and preferences, when/how to provide bed linen changes when the linens were soiled;

* Pet care;

* Use of compression stockings, when to apply and offer assistance related to leg swelling;

* Activity needs and preferences, including how to support the resident with spiritual and personal interests;

* Pain and effective non-pharmacological interventions;

* Behavior and mood, including how staff should respond; and

* Emergency evacuation needs.

The need to ensure Resident 6 and 7's service plans were reflective of current care needs and preferences and provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 09/20/22 and 09/22/22. They acknowledged the findings.

1. Administrator, RSC, and RN will equally divide up each resident's service plan to review for accuracy and detailed instructions on specifics to resident care and who is responsible for carrying out care tasks.

2. Administrator, RSC, and RN will implement a triple check system to review service plans that have been completed by one another for deficiencies .

3. Area needing correction will be evaluated quarterly by Administrator will audit 5 service plans using audit tool.

4. Administrator/RN will be responsible to see that all corrections are complete/monitored.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 5, 10 and 13) completed all required pre-service orientation training and 2 of 3 staff (#s 10 and 13) completed all required pre-service dementia training prior to beginning their job responsibilities. Findings include, but are not limited to:

Staff training records were reviewed on 05/17/22.

1. There was no documented evidence Staff 5 (CG), hired 03/03/22, Staff 10 (MT), hired 03/11/22, and Staff 13 (CG), hired 03/31/22, completed training related to the following required pre-service orientation topics:

* Abuse reporting requirements; and

* Standard precautions for infection control.

2. There was no documented evidence Staff 10 and Staff 13 completed training related to one or more of the required pre-service dementia topics:

* Dementia disease process including progression of the disease, memory loss, and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to behaviors;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities; and

* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.

The need to ensure newly hired staff completed all required pre-service orientation and dementia training prior to beginning their job responsibilities was discussed with Staff 1 (Administrator), Staff 2 (RN), and Staff 3 (Health Services Administrator) on 05/17/22. They acknowledged the findings.

1. Newly hired staff will receive abuse reporting requirements and standard precautions for infection control in the new hire paperwork completed by Front Office Manager. Front Office Manager has added the policy and infection control policy to new hire paperwork packets to be reviewed.

2. Front Office Manager has created checklist of requirements for newly hired employees and will turn in to Administrator when completed at time of hire.

3. Administrator will audit newly hired employee files for any dificiencies and address to correct immediately.

4. Administrator/Front Office Manager will be responsible to see that corrections are completed.

5.New hire employee files will be brought to quarterly QAPI meeting.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly-hired staff (#s 5, 10 and 13) demonstrated competency in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/17/22.

Staff 5 (CG), hired 03/03/22, Staff 10 (MT), hired 03/11/22, and Staff 13 (CG), hired 03/31/22, lacked documented evidence competency had been determined in all assigned job duties within the first 30 days of hire for topics including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional, and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving, and sanitation; and

* First Aid and abdominal thrust.

Staff 10 lacked demonstrated competency related to the administration of medication or treatments within 30 days of hire.

The need to ensure newly-hired staff demonstrated competency in all assigned job duties was discussed with Staff 1 on 05/17/22. She acknowledged the findings. The survey team instructed Staff 1 that Staff 10 must demonstrate competency related to the administration of medication prior to resuming job duties. A signed statement attesting to this was provided by Staff 1 (Administrator) prior to exit on 05/17/22.

1. Newly hired staff #5, 10, and 13 have demonstrated and completed competency checklists. Staff #5, 10, and 13 have been educated on the role of service plans in providing individualized resident care, ADL's, changes associated with normal aging, identifying changes in the resident's physical, emotional, and mental functioning, and documentation and reporting resident's change of condition, general food safety, serving, and sanitation. All staff have completed First aid and abdominal thrust documented in employee record.

2. Resident Services Coordinator and Health Services Coordinator will ensure their staff have demonstrated and completed competencies within 30 days of hire as well as first aid/abdominal thrust training and turn documentation into Administrator to be documented in employee record, or staff will be removed from schedule until completed.

3.Documentation of required training will need to be evaluated for corrections monthly.

4. Front Office Manager will be responsible for auditing employee files monthly for required training documentation completion. Audits will be given to Administrator for review.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 9, 11, and 15) completed the minimum required 12 hours of annual in-service training related to dementia and the provision of care in a CBC setting. Findings include, but are not limited to:

Review of facility training records on 05/17/22  revealed the following:

Staff  9 (CG), hired 05/10/06, Staff 11 (MT), hired 05/20/18, and Staff 15 (CG), hired 10/04/19, lacked documented evidence of completion of the required 12 hours of annual in-service training related to dementia and the provision of care in a CBC setting.

The need to ensure long-term staff completed all required annual training was discussed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

1. Front Office Manager will ensure all employees complete required 12 hours of annual in-service training related to dementia and the provision of care in a CBC setting via Relias Training.

2. Front Office Manager will alert/remind staff of required training and alert direct supervisor. Staff will be reminded they will be taken off of the schedule of annual training not completed as required.

3. Front Office Manager/Administrator will monitor monthly the status of all employee 12 hour annual trainings.

4.Front Office Manager/Administrator will be responsible to see that corrections are completed and being monitored, documented in staff record.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety documentation reflected all required fire drill components. Findings include, but are not limited to:

Fire drill records were reviewed from 12/01/21 through 05/16/22.

The following deficiencies were identified:

* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts;

* There was no documented evidence the facility was conducting fire and life safety instruction on alternating months from fire drills;

* The evacuation/drill documentation did not contain information on the escape route used, problems encountered, evacuation time period needed, evidence alternate routes were used during drills, and the number of occupants evacuated.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 05/17/22. She acknowledged the findings.

1. Maintenance Director/Administer will create a schedule for file drills and staff fire life safety instruction training on alternate months, beginning in June 2022. All staff will be in-serviced on fire life safety staff training. Fire drills will be scheduled to occur unannounced on alternating shifts every other month. Maintenance Director will document date and time of day, location of simulated fire origin, escape route used, problems encountered and comments relating to residents who resisted or failed to participate in the drills, evacuation time period needed, staff members on duty and participating and number of occupants evacuated in fire drill record. Fire life safety instruction staff trainings will be documented and kept with fire drill documentation.

2. Maintenance Director will audit fire drill records to ensure fire drills conducted contain all required information. Maintenance Director will adhere to the scheduled fire drills on alternating months. Administrator/Maintenance Director will adhere to alternating month schedule of fire life safety instruction staff training.

3. Maintenance Director/Administrator will review fire drill records and staff training monthly for the previous month. Administrator/Maintenance Director will bring any outliar data to QAPI quarterly.

4. Maintenance Director/Administrator will be responsible to see that corrections are completed and being implemented.

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

Refer to C 260.

Refer to plan of correction for C260.

Based on observation and interview, it was determined the facility failed to ensure pathway edges did not contain drop-offs in the resident outdoor area. Findings include, but are not limited to:

Observations on 05/16/22 of the facility courtyard and multiple resident-used pathways around the building showed drop-offs at the pathway edges in excess of six inches in multiple areas.

The need to ensure pathways did not have drop-offs which created potential tripping hazards was discussed with Staff 1 (Administrator) on 05/16/22.  She acknowledged the findings.

1. Administrator has been in contact with the facility landscapers and will be scheduling time for them to fill and lay bark dust in the resident outdoor areas where exceeding drop offs are present.

2. Administrator will schedule annual bark dust laying with landscapers.

3. Maintenance Director will complete walkthroughs of building exterior quarterly to ensure resident pathways are free from exceeding drop offs and assess if there is a need for interim bark dust laying outside of annual schedule.

4. Administrator will be responsible to see that bark dust is completed. Maintenance will monitor by quarterly exterior walkthroughs and bring report to QAPI quarterly.   

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

Observations of the facility on 05/16/22 showed the following areas in need of cleaning or repair:

* Chipped, scraped, and gouged areas on the walls and corners in multiple areas throughout the facility;

* Multiple door frames with scratched, gouged, and/or scraped areas and exposed bare wood;

* Hand rail on first floor with chipped area exposing bare wood;

* Third floor overlook ledge area had a section approximately eight feet long where sections of the paint were lifted and/or missing, exposing bare wood surfaces;

* Numerous dining room chairs on first and third floors had tears of varying sizes along the front of the seat area, with exposed foam areas beneath;

* First floor lobby/sitting area windows had multiple dead bugs on the window sills; and

* Wall and hand rail surfaces surrounding white boards mounted on each of the three floors were covered with black stains/smears.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 05/16/22. She acknowledged the findings and reported there was currently no maintenance director in the facility, although she had hired one to start later in the month.

1. Maintenance Director will begin cleaning and repairing building interior beginning with first floor, second, and third. Maintenance Director will repair chipped, scraped and gouged areas of walls and corners, sand and stain damaged doorframes and wood, hand rails. Maintenance Director will sand and repaint overlook ledge of third floor. Housekeeper will ensure windows are free of dust and window sill free of bugs and debris. Administrator will purchase fluid resistant dining room chairs, dispose of any chairs damaged beyond repair.

2. New Maintenance Director started 5/23/22 that will be able to keep up on interior repairs and cleaning.

3. Maintenance Director will complete monthly walkthrough inspections of building interior, repair and/or replace findings to ensure building interior is kept clean and in good repair.

4. Maintenance Director will be responsible to see that corrections are completed and will monitor monthly. Administrator rounds physical plant quarterly and ensures any building issues are addressed in a timely manner so that the building is in good repair.