The findings of the change of ownership survey, conducted 11/02/21 through 11/04/21, 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 revisit to the re-licensure survey of 11/4/21, conducted 1/25/22, 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 and interview, it was determined the facility failed to maintain the kitchens in clean and good condition. Findings include, but are not limited to:

Meals were prepared in the main kitchen in the independent living building and shuttled to the assisted living building kitchen to be served. The main kitchen was toured on 11/02/21 at 10:15 am; the ALF kitchen was toured on 11/02/21 at 11:00 am.

The following areas needed to be cleaned or repaired in the main kitchen:

* Multiple doors and door frames were grimy or damaged, exposing bare wood;

* Sugar and flour bins in the dry-storage area were dirty;

* The ice-scoop holder was covered with greasy residue;

* The blades and grate of a large, ceiling-mounted circular fan were covered with debris;

* A black table-top fan was covered with splatter and sticky residue;

* The underside of the motor housing of the large stand mixer and the smaller Kitchen Aid stand mixer had dried white-colored debris;

* Silver metal wall shelves over the prep counter in the cooking area and over the rear prep counter had sticky build-up;

* Backsplashes above prep counters had dried splatter;

* The back side of the blade of the meat slicer had dried red debris;

* The fan grates in the walk-in refrigerator were covered with debris; and

* There were two areas of the ceiling where the plaster had been damaged due to leaking water pipes.

The following areas needed to be cleaned or repaired in the assisted living building kitchen:

* There were dried coffee grounds on the wall behind the coffee machine;

* Laminate shelving was chipped, exposing bare wood, on shelves next to the three-door refrigerator and in the base cabinet under the microwave oven;

* There was dried splatter inside the microwave oven; and

* Uncovered bowls of ice cream were left in the freezer.

The areas needing cleaning and repair in both kitchens were reviewed with Staff 2 (ED) and Staff 4 (Food and Beverage Director) on 11/03/21 at 10:30 am. They acknowledged the areas needing cleaning and repair.

Check off sheets for scheduled cleaning and maintenance have been put into place for each shift and department.

Bids have been received for repairing the kitchen ceiling.  

The Food and Beverage Director, Dining Room Supervisor and Maintenance Director will inspect and document that the check off sheets for scheduled cleaning and maintenance are completed for each shift and department.  The Maintenance Director will see that the ceiling repairs are completed.

Scheduled cleaning and maintenance items will be evaluated on a daily basis. With corrections completed in an appropriate time frame.

Food and Beverage Director and Maintenance/Housekeeping Director.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled residents (#2) reviewed for new move-in evaluation. Findings include, but are not limited to:

Resident 2 was admitted to the facility in August, 2021.

Resident 2's move-in evaluation was completed on 08/11/21. Review of the evaluation revealed it failed to address:

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

* Environmental factors that impact the resident's behavior

including, but not limited to:

(A) Noise.

(B) Lighting.

(C) Room temperature.

The failure to address all required components of the move-in evaluation was shared with Staff 1 (Administrator) and Staff 3 (RN) on 11/04/2021. They acknowledged the findings.

The Evaluation Form will be changed to add a section under Behaviors for Personality:  Including how the resident copes with change and challenging situations.  We will also include a section regarding Environmental factors that impact the residents behavior,to include noise, lighting, room temperature etc.

Our Service Plan will develop interventions for coping with challenging situations and environmental factors listed in the initial Evaluation.  

Quarterly , or as needed,

The RN and the Administrator

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 1 of 5 sampled residents (#2) whose orders were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in August 2021 with diagnoses including thyroid dysfunction, hypothyroidism, and diabetes type II.

In interview on 11/03/21, Resident 2 reported concern about not getting his/her thyroid medication as ordered. Resident 2 stated it was supposed to be given an hour before breakfast, however, the medication techs were administering it with the other medications just before or with breakfast.  Resident 2 stated that when the meal and medications were brought together at 7:30 or 8:00 am, s/he would take the thyroid medication first, and then wait one hour to eat breakfast.

The 09/03/21 physician order for the thyroid medication read: "Levothyroxine (thyroid medication) 150 mcg Take 1 tablet by mouth daily on an empty stomach at 7 am."

Resident 2's October 2021 MAR read only "levothyroxine... take one tablet by mouth every day for thyroid" with the med pass time listed as 7:00 am.

In interview on 11/04/21, Staff 8 (Med Tech) confirmed the levothyroxine was given with Resident 2's other medications, all of which were scheduled for 8:00 am and given with breakfast.  Staff 8 reviewed the MAR before giving medications, however, the MAR did not have any specific instruction to give the medication on an empty stomach or before food was served.

The need to ensure all physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 11/04/21. They acknowledged the findings.

AM Med-Techs were gathered together and informed of the necessity of giving medications as scheduled.  A Med-Tech meeting is also scheduled for 12/6/21 at which time the survey/med issues will be reviewed with all Med-Techs.

The RN and Administrator will do periodic checks on Med Administration and Med Pass to ensure early morning meds are given on time.  They will also talk to residents receiving early meds to assure the system has been corrected and meds are being given according to doctors orders.

The RN will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to maintain an accurate medication administration record (MAR) for 1 of 5 sampled residents (#4) whose MARs were reviewed. Findings include, but are not limited to:

Resident 4 had signed physician orders for three different PRN topical products to treat different skin conditions. The orders included specific instructions for when to administer each medication. For instance, "Treatment for redness or irritation secondary to urinary incontinence: Calmoseptine ointment" and "Treatment for redness or irritation secondary to moisture in skin folds: Gold Bond Medicated Powder."

However, the specific instructions had not been transcribed to the 9/2021 or 10/2021 MARs. Instead, the MARs read only:

* Chamosyn (calmoseptine equivalent) ointment "for irritation or as preventative treatment";

* Gold Bond Ultimate Powder apply "to affected area"; and

* Hydrocortisone ointment "for dry, red, itchy skin."

The need to ensure the MAR included resident-specific parameters and instructions for PRN medications to guide unlicensed staff in correctly administering medications was reviewed with Staff 1 (Administrator) and Staff 3 (RN) on 11/04/21. Staff 3 explained staff were supposed to affix small stickers with the parameters to the MAR. Staff 1 and Staff 3 acknowledged the facility had failed to ensure the parameters were in place on Resident 4's MARs.

The Mars will be audited to assure that parameters for prn use and any interventions needed for prn use are in place.

The RN and RSC will audit parameters monthly during the Mar recaps.  New prn orders will have parameters set at the time the order is received. RN and RSC will discuss prn order problems/issues with medical records at Pharmacy.

Monthly during Mar recaps.

The RN will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure all required annual training was completed for 2 of 2 sampled veteran care staff (#s 15 and 16) whose training records were reviewed. Findings include, but are not limited to:

Review of staff training records and an interview with Staff 1 (Administrator) on 11/03/21 identified the following deficiencies:

The records lacked documented evidence that Staff 15 (CG) and Staff 16 (CG) completed at least 12 hours of annual training on provision of care in a community-based care setting, including at least six hours of dementia training.

On 11/04/21 the need to ensure all annual training requirements were completed by care staff, based on anniversary dates of hire, was discussed with Staff 1, Staff 2 (Executive Director) and Staff 3 (RN). They acknowledged the findings.

The RSC and the Administrator will make sure that all caregivers complete all classes that have not been

completed and turned in.

Within COVID parameters and guidelines monthly classes will be held in person and completed monthly. When this is not feasible, then the caregivers will be assigned the monthly class using Oregon Care Partners classes.  The Certificates will be collected within the month and anyone not turning in their certificates will not be allowed to come to work until it is completed. This will be done monthly.

The Administrator will be responsible to see that all Certificates are completed on time.  The RSC will be responsible to see that all caregivers are given the classes and that they complete their classes on time.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

During the entrance conference on 09/21/21, the surveyor requested fire and life safety training records from February 2021 through August 2021. The following was identified:

There was no documentation residents were re-instructed at least annually on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire.

The need to ensure all general fire and life safety requirements were met was discussed with Staff 1 (Administrator) and Staff 5 (Director of Plant Operations) on 11/3/21. They acknowledged the findings.

The Service Plan will have a section added for Fire Life Safety.

The Administrator will review the Fire Life Safety during quarterly Service Plans with the resident and the families to ensure that the resident has a full understanding of fire drills, emergencies, evacuations, and escape routes.  If a residednt is unable to understand or retain the instructions the service plan will reflect this to ensure staff will assist the resident to a safe staging area.

Quarterly, during the Service Plan update.

The Administrator will be responsible to see that this is done on each SP update.