The findings of the re-licensure survey, conducted 07/11/22 through 07/12/22, 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 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 1st revisit to the re-licensure survey of 07/12/22, conducted 11/21/22 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 interview and record review, it was determined the facility failed to ensure incidents of abuse or suspected abuse were thoroughly investigated and reported to the local SPD when abuse was not reasonably ruled out for 1 of 1 sampled resident (#2) whose facility record was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 08/2015 with diagnoses including heart failure.

Review of the resident's 04/11/22 through 07/11/22 facility record revealed the following:

The resident's 06/02/22 service plan indicated the resident had "confusion due to dementia."

A progress note dated 06/28/22, and subsequent incident investigation dated 06/29/22, indicated Resident 2 was found on the ground outside of the building, at the base of four stairs with skin tears on both hands and two bumps on his/her head. Staff stated in the 06/29/22 investigation that the resident "wheeled self off the stairs looking for dead wife in a state of dementia."

There was no documented evidence the facility had completed a thorough investigation that reasonably ruled out abuse and failed to report the unwitnessed fall with injury to the local SPD.

The need to ensure incidents of abuse or suspected abuse were reported to the local SPD when abuse was not reasonably ruled out was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 07/12/22. They acknowledged the findings. The facility was instructed to report the incident to the local SPD. A fax confirmation of the report was provided prior to exit.

TAG C231:

1)Incident reported for resident #2 to Oregon SPD  on 7-12-22 by facility Administrator.

2)The facility investigative form was reviewed and updated to include medication review, witness statements, investigation results,  background information, RN Consultant review and Administrator review and analysis to make final decision on investigative outcome and to report to SPD or not          AND

All facility staff  and Facility RN were in-serviced on 7-22-22 regarding incident reporting/investigation process including definitions of, and mandatory reporting of suspected and/or actual abuse  and re-educated on what  the components of an investigation are, what is an in-depth review of all clinical , environmental and behavioral factors that may be contributing to an event and the importance of the analysis of this information to come to a conclusion  of the event  for known  or unknown cause  by the facility Administrator.  

3)All incident investigations will be reviewed by the Administrator and RN Consultant as they occur                          AND                                                     

Monthly Audits will be done by the Administrator to assure all incident reports are investigated and action plans will be implemented based on their analysis post audit.                               

AND                                                                         Facility Incident/investigation policy will be reviewed annually and revised as needed by the Administrator.

4)Administrator will be responsible for completion and monitoring of all incident reports.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained clean and in good repair, and that proper infection control practices were implemented in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

A tour of the kitchen conducted on 07/11/22 at 9:35 a.m. and observation of the lunch service the same day revealed the following:

a. An accumulation of food spills, splatters, dirt, dust, black matter, scuffs, and grease was visible on or underneath the following:

* Walls;

* Doors;

* Drains;

* Pipes under sinks, behind fryer, grill and stove;

* Shelving units in kitchen, dry storage, and walk-in cooler;

* Electrical outlets, light switches, and fire alarm;

* Trash cans;

* Ceiling tiles;

* Large industrial stand mixer;

* Table-top stand mixer;

* Can opener;

* Fan in walk-in cooler;

* Small oscillating fan near screen door;

* Window sills;

* Exit door and screen door; and

* Floors throughout the kitchen had black matter build-up, food debris and grease in corners, under equipment, and around perimeter edges.

b. The following areas were in need of repair:

*  Multiple door frames throughout the kitchen had chipped paint;

* The caulking behind the steam table and adjacent food prep area was yellow with build-up of brown matter on the edges;

* The industrial stand mixer had chipped paint;

* The seam of the vinyl flooring in dish storage room was pulling away from the floor beneath;

* The laminate on the cabinets/shelves in the utensil/dish storage room was chipped with raw wood exposed;

* Metal shelves below food prep tables and the shelf the industrial mixer sat on had areas where rust had developed;

* There were holes in the door to the freezer and areas where rust had developed;

* There were multiple small holes in the walls throughout the kitchen;

* Ceiling tiles throughout the kitchen were discolored;

* A peg board with hanging utensils had chips in laminate; and

* The deli table was not operational.

c. The following improper infection control practices were observed and/or reported on 07/11/22:

* During an interview with Staff 4 (Kitchen Manager) on 07/11/22 at 10:00 a.m., she reported the facility thaws meat on a shelf above the eggs in the walk-in cooler.

* Staff 4 was observed to lift the lid of a garbage can to dispose of a paper towel after she had washed her hands.

* Staff 4 was observed to rinse the probe thermometer off in the bucket of sanitation solution used to wash food prep areas.

* There was a broom stored with the brush portion upright next to a shelving unit that had open boxes of plastic utensils.

* A staff member's sweat jacket was hanging on a rolling cart with clean dishes on it.

* A staff member's purse was sitting on a shelf in the dry storage closet.

The need to ensure the kitchen was maintained clean and in good repair and effective methods of infection control were implemented was discussed with Staff 4 following the kitchen tour and lunch meal service on 07/11/22, and with Staff 1 (Administrator) on 07/12/22. They acknowledged the findings.

TAG C240:

1)Deep cleaned kitchen, storage areas and walk-ins. Contractor has been contacted for the needed for kitchen repairs. Ceiling tiles, caulking of steam table wall area, adjacent food prep area, floor replaced in dish storage area, wood shelves in dish area removed. Contractor: Kaufman's Home Maintenance is scheduled for assessment on 8/2/22 at 10:00 am.

2)The dish aide and cooks weekly and monthly cleanings lists were reviewed and revised      

AND

Dietary staff were in-serviced on 7-22-22 regarding kitchen sanitation and food safety awareness by the facility Administrator.  

3)The dietary Manager will ensure lists are followed and completed weekly and monthly and will submit completed lists to Administer for review.                                                                  AND                                                                       

The Administrator will review lists once weekly and monthly for compliance.

4)Dietary Manager will be responsible for assuring  that daily cleaning tasks are completed and The Administrator will be responsible for monitoring for compliance.

2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including heart failure.

Review of the resident's 06/02/22 service plan, observations of the resident, and interviews with staff revealed the service plan was not reflective of the resident's care needs and did not provide clear instruction to staff in the following areas:  

* Ability to use call light;

* Two-person transfers;

* Evacuation assistance;

* Skin tear on elbow and abrasions on knees; and

* Communication.

The need to ensure the resident's service plan was reflective of his/her current status and care needs and provided clear direction to staff was discussed with Staff 3 (RN) on 07/12/22. Staff 1 (Administrator) indicated later that day that Staff 3 had reviewed the information with her and did not need to review it further. Staff 1 and Staff 3 acknowledged the findings.

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

1. Resident 1 was admitted to the facility in 12/2019 with diagnoses including diabetes, heart failure, and edema.

A review of the resident's 04/19/22 service plan, interviews with staff and the resident, and observations of ADL care on 07/12/22 revealed the resident's service plan was not reflective in the following areas:

* Level of assistance needed for ADL care; and

* Use of side rails.

The need to ensure service plans accurately reflected the current care needs of residents was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 07/12/22. They acknowledged the findings.

TAG C260:

1)Resident #1: Administrator and RN reviewed and revised resident #1 service plan to accurately reflect residents current ADL assistance needed and educated staff on changes to the service plan.

Resident #1: Facility RN assessed resident #1 for the  appropriateness and  need for side rails and had an informed discussion with resident and family regarding risks associated with use of this dme and the potential restraining qualities and updated service plan to reflect resident preference.

Resident #1: RN will assess assistive devices quarterly.

Resident #1: Maintenance will document any assistive devices in the maintenance log and check for dme for need of repair.

Resident #2: Administrator and RN reviewed and revised resident #2 service plan to accurately reflect resident's current ADL assistance and educated staff on changes to the service plan.

Resident #2: RN assessed skin tear on elbow and abrasion on knees and added to TAR for monitoring.

2)Administrator will review 100% of residents service plans to assure they reflect current ADL/needs of resident.

RN will complete restraint audit to assure that all components are in place for use of restraint with each resident that has restraint in facility.

3)Administrator and RN will review/update service plans quarterly and as needed to reflect care changes.

4)RN  will be responsible for assuring  that restrictive/restraining dme evaluation/updates are completed and the Administrator is responsible for monitoring service plans to assure they are  reflective of resident's current needs.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 3 sampled residents (#1) whose MAR and physician orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2019 with diagnoses including diabetes, heart failure, and edema.

Review of the resident's 07/01/22 through 07/11/22 MAR and signed physician orders revealed the resident had an order for Humalog (insulin) to be administered three times per day as needed with meals. The amount of insulin administered was based on the resident's CBG level according to the following sliding scale:

* 150 - 199: 4 units;

* 200 - 249: 6 units;

* 250 - 299: 8 units; and

* 300 - 350: 10 units.

On three occasions, 07/04/22 (before dinner), 07/07/22 (before lunch), and 07/08/22 (before lunch), documentation on the MAR indicated the resident had been administered insulin when his/her CBG was under 150.

The need to follow physician orders as written was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 07/12/22. They acknowledged the findings.

TAG 303:

1)Resident #1: RN reviewed and revised order in computer to reflect sliding scale <150 prompts Med Aides not to give (0) Insulin.  Thus MAR will reflect accurately that resident was not give any Insulin based on CBG reading.

2)RN will complete 100% audit on all  diabetics Insulin administrations to assure resident is insulin orders are written/transcribed appropriately to prevent future errors.

Administrator and RN held MA Meeting educating Med Aides on 7/20/22 reviewing diabetic policy/procedures for diabetics, following parameters as ordered, and notifying Physicians if orders does not have a parameter and/or when the Physician wants to be notified or when the Insulin should be held.

3) RN will complete diabetic audit to every week for four weeks to assure that all components are in place for use of Insulin administration and thereafter once quarterly and submit audits to Administrator.

4)Administrator will monitor to assure that audits are completed monthly.     

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (#3) who had documented medication refusals. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 07/2021 with diagnoses including diabetes.

Resident 3's 04/12/22 through 07/11/22 progress notes, physician communications, and 06/01/22 through 07/11/22 MARs were reviewed. The resident's record showed multiple refusals of Humalog insulin.

There was no documented evidence the facility notified the physician each time the resident refused to consent to the orders.

The need to ensure the facility notified physicians of medication refusals was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 07/12/22. They acknowledged the findings.

TAG 305:

1)Resident #3: Physician was notified of refusals and order was received with parameter to notify physician once weekly of resident's refusals to take insulin.

2)RN will complete 100% audit on all diabetics to ensure parameters are in place for refusals of Insulin administration.  

Administrator and RN held MA Meeting educating Med Aides on 7/20/22 reviewing diabetic policy/procedures for diabetics, following parameters as ordered, and notifying Physicians if orders does not have a parameter and/or when the Physician wants to be notified or when the Insulin should be held.

3)RN will complete diabetic audit every week for four weeks to assure that all components are in place for use of Insulin administration, whether there has been a refusal of insulin and if physician has been notified  and thereafter once quarterly and submit audits to Administrator.

4)Administrator will monitor to assure that audits are completed monthly.     

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legal prescriber and for which the facility was responsible to administer for 1 of 3 sampled residents (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2019 with diagnoses including diabetes.

A review of his/her 07/01/22 through 07/11/22 MAR and physician orders revealed the resident had an order for sliding scale Humalog (insulin), to be administered based on his/her CBGs prior to each meal.

There were multiple instances where the resident's CBG was outside the parameters of the Humalog sliding scale order, and it was unclear whether or not the insulin had been administered when it should not have been.

In an interview with Staff 3 (RN) on 07/12/22, she acknowledged staff were not all documenting insulin administration, or the withholding of the medication per physician order, in the same way when the CBG was outside the parameters.

The need for the MAR to accurately reflect whether medication was administered or not was discussed with Staff 1 (Administrator) and Staff 3 on 07/12/22. They acknowledged the findings.

TAG 310:

1)Resident #1: Order was requested from MD to discontinue previous parameter for notification of CBG greater than 300.  New orders reflect the Hospice physician parameter of notification of greater than 350 will be the only order on the MAR for notification on the physician for residents CBG's.

2)RN will complete 100% audit on all diabetics to ensure parameters are in place for refusals of Insulin administration.  

Administrator and RN held MA Meeting educating Med Aides on 7/20/22 reviewing diabetic policy/procedures for diabetics, following parameters as ordered, and notifying Physicians if orders does not have a parameter and/or when the Physician wants to be notified or when the Insulin should be held.

3) RN will complete diabetic audit every week for four weeks to assure that all components are in place for use of Insulin administration, assuring parameters are in place of when to notify physician and if not placing parameter until order from physician has been obtained and thereafter once quarterly and submit audits to Administrator.

4)Administrator will monitor to assure that audits are completed monthly.         

Based on observation, interview, and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed by the facility RN, a PT, or an OT, caregivers instructed in the correct use and precautions related to the device, and use of the device included in the service plan for 1 of 3 sampled resident (#1) who used supportive devices. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 12/2019 with diagnoses including diabetes, heart failure, and edema.

Review of the resident's facility record, observations of the resident's bed and staff performing ADL care on 07/12/22, and an interview with staff revealed the following:

* Quarter side rails were on both sides of the resident's hospital bed;

* There was no documented evidence of an assessment for a device with restraining qualities had been completed by an RN, PT, or OT; and

* There were no documented instructions to staff regarding the correct use of and precautions related to the use of side rails.

In an interview on 07/12/22, Staff 3 (RN) verified she had not completed an assessment for the use of side rails or included the use of the device in the resident's service plan.

The need to ensure an assessment of any device with restraining qualities was completed by an RN, PT, or OT and was included in the resident's service plan was discussed with Staff 1 (Administrator) and Staff 2 on 07/12/22. They acknowledged the findings.

TAG C340:

1)Resident #1: Facility RN assessed resident #1 for the  appropriateness and need for recliner and had an informed discussion with resident and family regarding risks associated with use of this dme and the potential restraining qualities and updated service plan to reflect resident and family preference to continue this dme despite risks discussed.  Recliner was added to residents service plan as an assistive device.

Resident #1: RN will review assistive devices quarterly.

Resident #1: Maintenance will document any assistive devices in the maintenance log and check for dme for need of repair.

2)Administrator will review 100% of residents service plans to assure they reflect current ADL/needs of resident.

RN will complete restraint audit to assure that all components are in place for use of restraint with each resident that has restraint in facility.

3)Administrator and RN will review/update service plans and restraints quarterly and as needed to reflect care changes.

4)RN  will be responsible for assuring  that restrictive/restraining dme evaluation/updates are completed and the Administrator is responsible for monitoring service plans to assure they are  reflective of resident's current needs.   

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 3 of 3 sampled residents (#s 1, 2, and 3) whose records were reviewed. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST which would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents.

On 07/12/22, Staff 1 (Administrator) reported the facility had not implemented an ABST. Staff 1 stated she would follow up to ensure the ABST was implemented as required.

1. Administrator will complete the Acuity Based Staffing tool for all residents.

2.Administrator will continue reviewing and updating LTC staffing tool.

3. Administrator will review at admission,30 days,90 day and as needed for any change of condition.

4. Administrator

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC).  Findings include, but are not limited to:

Review of facility records on 07/11/22 identified the following deficiencies:

There was no documented evidence annual training on fire safety was provided to residents.

On 07/12/22 the need to provide and document fire and life safety instruction for residents at least annually, in accordance with the OFC, was discussed with Staff 1 (Administrator) and Staff 5 (Maintenance). They acknowledged the findings.

1. Current residents given Fire Life Safety training and checked off Roster for those cognitively able to understand training. Maintenance staff will annually review Fire Life Safety training with all residents.

New residents will be given training at admission.

2. Upon admission residents will receive fire and life safety training and annually.

3. Administrator will review quarterly during service plan meeting to ensure fire and life safety training is complete.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:

The exterior grounds were toured on 07/11/22 at 10:05 am. There were drop-offs of up to four inches along the edges of multiple pathways and around a covered patio area. These drop-offs created potential tripping or fall hazards for residents.

On 07/12/22 the surveyor toured the outdoor grounds with Staff 1 (Administrator), observed the drop-offs, and explained the need to properly maintain the building's exterior. She acknowledged the findings and stated immediate plans would be put in place to fix the issues.

1. Maintenance contacted outside provider to rectify the drop-off height inequalities.  Green Works Companies, LLC 503-303-8368, will complete

areas around the building exterior until all drop offs are within no more than a 2 inch difference.

2. Maintenencce will walk through the outside parimeter and report any findings to Administrator on a monthly basis.

3. Monthly

4. Administrator