The findings of the relicensure survey, conducted 03/28/22 through 03/31/22, 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 re-visit to the re-licensure survey on 03/31/22, conducted on 06/28/22, 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.

Based on observation, interview and record review, it was determined the facility failed to ensure an injury of unknown cause was promptly investigated to rule out possibility of abuse or neglect and was reported to the local SPD office when unable to reasonably conclude the incident was not abuse or neglect for 1 of 1 sampled resident (#4). Findings include but are not limited to:

1. Resident 4 was admitted to the facility in 2018 with diagnoses including multiple fractured ribs.   

Observations of the resident on 03/30/22 revealed the resident required staff assistance with transfers.

Review of incident reports from 01/14/22 through 03/07/22 showed the following:

* 03/07/22 incident report identified Resident 4 had a wound to the left lateral leg, measuring 2.5 cm x 1.5 cm. "...did not know how this wound occurred."

There was no documented evidence the facility conducted an immediate investigation to reasonably conclude the unknown injury was not the result of abuse or neglected care.

The failure to investigate unknown physical injury and to report to local APS when the facility's investigation was unable to rule out abuse was discussed with Staff 1 (ED), Staff 2 (RN/Health Service Director) and Staff 3 (Administrator) on 03/30/22. The incident was reported to the local SPD office per request of the surveyor. Confirmation the incident had been reported was received on 03/31/22.

1.C231, Abuse Reporting and Investigation:

a.Abuse Reporting and Training, monthly training, refreshed and presented during all-staff, built upon the "Abuse Reporting and Investigation Guide for Providers" created by ODHS. Which, includes training to care staff and managers to investigate and report injuries of unknown cause.

2. Abuse Reporting and and Investigations will be completed with each incident report that occurs for all residents.

3. Abuse Reporting and Investigations will be monitoried and comleted by RSCs, Administrator and RN as needed.

4. Health Services team are responsible as outlined above to ensure issue is corrected.  

Resident 4- Incident report completed for L lateral leg wound and report submitted to APS on 3/31/22 prior to surveorys exit.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The kitchen was toured on 03/28/22 at 10:25 am. The following areas were identified as needing cleaning or repair:

* By the ware-washer, there was a build-up of mold on the wall above the seam and above the metal panel;

* The lids and sides of dry storage bins had caked on food debris and dust;

* Whipped topping stored in plastic bags were not labeled. Whipped cream topping was dripping from the bag onto the floor of the refrigerator;

* Ice cream in a small freezer was not covered. There was melted ice cream along the edges of the inside freezer and there was build-up of ice in the freezer;

* There was build- up of food debris and dust on metal storage shelves where clean serving bowls and plates were stored;

* On the commercial oven and stove, there was a heavy build-up of dark brown and black grease on the metal burners and inside the oven. The doors and sides of the oven had a build-up of grease and food debris particles;

* The floor in front of, behind, and along the sides of the commercial oven had a heavy build-up of dark brown and black grease, sticky matter;

* A steamer was not clean and in good repair. It was not being used due to being broken. The handles and shelves inside had a sticky build-up of grease;

* Multiple drains on the floor in the kitchen had a heavy build-up of dirt and debris;

* Below the handwashing sink and across from the dry storage room, there was a build-up of dirt and debris on the floor and on the pipes;

* The meat slicer had a build-up of dried food debris;

* A waffle iron had a build-up of grease and sticky matter on the handle and top cover; and

* Two walk-in freezers both had a build-up of food debris on the floor.

The need to ensure the kitchen was clean and maintained in accordance with Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 03/28/22 at 1:45 pm. She acknowledged the findings.

C 240  # 1 & #2 Main Kitchen was thoughly cleaned.  New equipment has been ordered.  #3 & # 4 Kitchen cleaning task list has been updated and is being monitored/audited by Executive Chef weekly/monthly as outlined on list.

*  By the ware-washer, the caulking was replaced before survey team left.

* The lids and sides of dry storage bins have been cleaned.

* Whipped topping was cleaned and labeled before survey team left.

*Ice cream in a small freezer was defrosted and cleaned before survey team left

* metal storage shelves where clean serving bowls and plates are stored were cleaned before survey team left;

*On the commercial oven and stove, have been cleaned but cannot be restored to new finish due to years of use.  New equipment has been ordered.

*The floor in front of, behind, and along sides, of the commercial oven has been cleaned;

*A steamer was not clean and in good repair. It was not being used due to being broken. It has been removed and new equipment has been ordered.;

*Multiple drains on the floor in the kitchen were cleaned before survey team left.

*Floor below the handwashing sink and across from the dry storage room has been cleaned.

*The meat slicer and waffle iron have been cleaned.

*Two walk-in freezers floor has been cleaned.

Based on interview and record review, it was determined the facility failed to evaluate and monitor service-planned interventions for 1 of 3 sampled residents (# 3) who experienced short-term changes of condition related to falls. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension.

A significant change of condition assessment dated 02/25/22 noted the resident experienced an unwitnessed fall resulting in an emergency room visit and was diagnosed with a fracture of the right patella. The service plan was updated and noted the resident required assistance with bathing, dressing, applying a knee mobilizer, contact assistance with mobility one to four times a day and stand by assistance with toileting three to five times a day.

Incidents reports dated 02/26/22 through 03/03/22 noted the following:

* 02/26/22 Resident 3 was found on the bedroom floor and stated, "...trying to get up to use the bathroom";

* 03/02/22 Resident 3 was found on the floor on his/her back and stated, "...trying to close [his/her] blinds...lost balance"; and

* 03/03/22  Resident 3 attempted to sit on his/her armchair, sat on the the arm and slid off injuring his/her tailbone. The resident was sent to the emergency department for an evaluation.

There was no documented evidence the facility had monitored previous fall interventions including when the resident had last been assisted or offered toileting assist to ensure staff were following the interventions after each fall.  

Reviewing service planned interventions to determine appropriateness and effectiveness was discussed with Staff 2 (Health Services Director) and Staff 3 (Administrator) on 03/31/22 at 10:30 am. Staff acknowledged the findings.

C270, Change of Condition and Monitoring:

1.Staff training provided on POC (point of care). POC is the software system we use to track changes to resident's care that is outside of what is currently service planned. RSC to provide initial POC training of all new hires.  RSC to perform monthly training on POC during mandatory monthly all staff training.  

2.Caregivers have the option to document point-of-care services that populate on the RSC's dashboard, in order to capture changes of condition, both short term and long term. RSC will review dashboard daily and will report at daily health services meeting of any changes.

3.Short term changes of condition to be monitored via alert charting, and service plan updated as needed, including effectiveness of interventions. RSC will review alerts daily and implement any short term changes of conditions needed.

4.Significant changes of condition to be monitored via PCC software, prompting the RN to monitor interventions for effectiveness and recommending changes to the service plan as needed, including effectiveness of interventions. Significant changes of condition to be reviewed daily by RN at health services meeting. Interventions will be investigationed by RSC with each incident report that occurs for all residents.

Resident 3- Incident report has been updated with investigation of how previous fall interventions were utilized with falls that were reported

Based on observation, interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (# 3) whose MAR and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 11/2019 with diagnoses including hypertension and was diagnosed with a right patella fracture in 02/2022.

Resident 3 had an order for Hydrocodone/Acetaminophen 5/325 mg tab every six hours as needed for pain.

The Controlled Substance Disposition Log and MAR reviewed from 02/25/22 through 03/04/22 noted on three occasions staff signed the drug disposition log that the PRN medication was given. However, the MAR lacked documented evidence the resident received the medication.

The discrepancies between the drug disposition log and the MAR was reviewed with Staff 1 (ED) and Staff 3 (Administrator) on 03/30/22 at 3:50 pm. Staff acknowledged the findings.

C302, Systems: Tracking Controlled Substances:

1.Use the Supplemental Feature to prompt the med tech to document the number of narcotics on the MAR to the Narcotic Book.

2.Monthly audit of Narc book to MAR will be completed by RN.

3.      Retraining with med techs to occur on 4/22/22 on PCC and documentation requirements and use of supplemental features in PCC for narcotic administration

4.RN is responsible as outlined above to ensure issue is corrected.  

Resident 3- Investigation has been completed for narcotic book and PCC discrepencies. Medication error report completed for medication given early and PCC late entry edits completed to reflect accurate MAR.