The findings of the re-licensure survey, conducted 05/02/22 through 05/04/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.

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 revisit to the re-licensure survey of 05/04/22, conducted 07/19/22 through 07/20/22, 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.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against conditions that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

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

On 05/03/22 at 2:01 pm, the surveyor observed Staff 12 (CG) and Staff 13 (CG) provide incontinent care to Resident 1. During the observation, Staff 12 failed to change gloves after removing a soiled incontinent product and wiping fecal matter from Resident 1's bottom and perineum. Staff 12 touched the resident's clean blanket, clean incontinent brief and applied barrier cream to the resident's bottom while wearing the same soiled gloves.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (Administrator) on 05/03/22 at 2:18 pm. Staff acknowledged the findings.

A verbal review was done with staff #12 on the importance of infection control and changing gloves in between dirty and clean tasks. All staff to watch Infection Control- Basic Concepts through Oregon Care partners.

Caregiver observations will be done routinely.

Quarterly

Resident Care Coordinator/Executive Director

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

Resident 2 moved into the facility in March 2022. The following required elements were not addressed:

* Customary eating routine;

* Cultural preferences and traditions;

* Mental health issues, including effective non-drug interventions for documented mood/behavior issue; and

* Memory and decision-making abilities.

The need to ensure the initial evaluation included and addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (Resident Care Coordinator), and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the findings.

Training/Review with RN and RCC on filling out assessments/service plans completely, documenting on all required elements at time of initial screening, move-in, quarterly, and change of condition assessments.

All assessments/service plans will be reviewed by both RN and RCC to double check all required elements have been addressed.

Prior to admit and weekly for quarterly and change of conditions.

Executive Director will monitor screening and move-in evaluations prior to move in. Administrative Assistant will monitor quarterly and change of condition assessments/service plans.

2. Resident 1 was admitted to the facility in 2018 with diagnoses including hypertension and right knee pain.

Observations of the resident, interviews with staff, the current service plan and clinical records were reviewed during the survey, from 05/02/22 thru 05/04/22, revealed Resident 1's service plan was not reflective of the resident's status and did not provide clear direction to staff regarding the delivery of service in the following areas:

* Transfer status;

* Hospice service including when to contact and who to contact;

* Grooming;

* Dining preference;

* Activity status;

* Use of air mattress status; and

* Use of oxygen including who is to change the filter and tubing.

On 05/03/22 and 05/04/22, service plans were discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the service plans were not reflective of the resident's status and lacked clear instructions.

3. Resident 4 was admitted to the facility in 2019 with diagnoses including congestive heart failure and anticoagulation therapy.

Observations of the resident, interviews with staff and the current service plan reviewed during the survey, from 05/02/22 thru 05/04/22, revealed Resident 4's service plan was not reflective of the resident's status in the following:

* Bathing status; and

* Dressing.

On 05/03/22 and 05/04/22, service plans were discussed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the service plans were not reflective of the residents status.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of the resident's current needs, provided clear direction to staff regarding the delivery of services, were reviewed quarterly and were followed, for 3 of 7 sampled residents (#s 1, 4 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 2014 with diagnoses including history of behavior problems and acute encephalopathy due to phenytoin toxicity and possible opioid use.

During the survey, observations were made of the resident, interviews were conducted with another resident and multiple staff, and Resident 7's service plan and the last 60 days of progress notes were reviewed.

Resident 7's service plan included dated entries/updates describing various behaviors the resident had exhibited toward other residents and staff since moving into the facility.

* The service plan did not always provide instructions for staff as to how to respond to each of the behaviors.

* The service plan directed staff to notify the MTs "of any issues" so that the incident could be charted in the facility system. However, the service plan lacked clear instructions as to where or how to document (communication binder, progress note, incident report, alert charting, etc) and when to notify the administration team of an incident.

* The service plan directed staff to "remind [resident] to be kind to [his/her] neighbors and treat them as [s/he] would like to be treated" when staff witnessed Resident 7 making fun of other residents, calling them stupid, or making snide comments about them. In an incident dated 5/3/22, staff documented Resident 7 continued to make comments regarding a previous resident altercation in the presence of the other resident, and staff responded only by asking the resident to "drop it" rather than responding as instructed in the service plan.

The need to ensure the resident's service plan provided clear direction to staff regarding the delivery of services was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the need to add additional instructions for staff regarding documentation and reporting.

Training/Review with RN and RCC on filling out assessments/service plans completely. Documenting on all required elements and including interventions/instructions for staff on how to respond in different situations, at time of initial screening, move-in, quarterly, and change of condition assessments.

All assessments/service plans will be reviewed by both RN and RCC to double check all required elements and interventions/instructions have been addressed.

Prior to admit and weekly for quarterly and change of conditions.

Executive Director will monitor screening and move-in evaluations prior to move in. Administrative Assistant will monitor quarterly and change of condition assessments/service plans.

Based on interview and record review, it was determined the facility failed to consistently determine and document what action or intervention was needed for a resident and ensure the documentation of staff instructions was made part of the resident record in response to a short term change of condition, for 2 of 7 sampled residents (#s 2 and 3) who had a medication change and a skin injury. Findings include, but are not limited to:

Resident 2 and 3's current service plans and last 90 days of charting notes were reviewed during the survey. The following deficiencies were identified:

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

A charting note dated 03/31/22 stated was on "Alert Charting" for a new medication - Melatonin.

There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident record.

2. Resident 3 was admitted to the facility in 2021 with diagnoses including osteoarthrosis, osteoporosis and chronic pain in the hip and lower extremity joints.

A charting note dated 03/12/22 stated the resident was being placed on "Alert Charting" after sustaining a minor skin tear on the wrist.

There was no documented evidence actions or interventions were determined and documented for staff and made part of the resident record.

The need to ensure the facility documented what action or intervention was needed for a resident following a short term change of condition was discussed with Staff 1 (Administrator), Staff 2 (RN), Staff 3 (RCC) and Staff 7 (RN Consultant) on 05/04/22. They reported MTs were instructed to document instructions in the Alert Charting note, and that this had not been done.

Inservice/Training with all MT's to go over med changes, skin alert, monitoring, and interventions. When to place on TCOC vs COC.

RN/RCC to review alert charting daily to ensure timely change of condition and proper documentation into service plans.

Daily in morning meeting, and as needed.

Executive Director

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care, for 1 of 3 sampled residents (# 1) who received hospice services. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2018 with diagnoses including hypertension. During the acuity interview, the resident was identified to receive hospice services.

Resident 1 was observed on 05/03/22, with the following:

* Oxygen therapy, setting of 4L/min;

* Use of air mattress on bed;

* A surgical wound dressing on the right hip area; and

* A foam dressing on coccyx area.

The resident's clinical record was reviewed and identified the following:

* A physician order dated 04/26/22 indicated a flow rate of 2L/min of oxygen;

* There was no information regarding the resident was using an air mattress; and

* There was no documented evidence the facility was monitoring a surgical wound nor was there documentation the resident had a wound to the coccyx area.

The above findings were discussed with the following staff and revealed:   

* 05/03/22 at 2:01 pm, Staff 12 (CG) stated the air mattress was delivered when the resident was enrolled to hospice service on 04/26/22. She was not aware of an open wound on the coccyx area;

* 05/03/22 at 3:20 pm, Staff 2 (RN) stated the hospice team managed the resident's surgical wound on the right hip area, and it was not managed by the facility staff; and

* On 05/04/22 at 2:30 pm, Staff 2 and Staff 3 (RCC) stated the hospice team increased the oxygen to 4L/min on 04/29/22 when they visited the resident. However, it was not communicated to the facility staff. She further stated there was no open wound to the resident's coccyx area and was unsure why a dressing had been placed.

The need to ensure on-going coordination of care with an outside service provider was discussed with Staff 1 (Administrator), Staff 2 and Staff 3 on 05/04/22. They acknowledged the findings.

Traning/Review with RN, RCC, MT's, and Caregivers on communication with outside agencies and within to report new equipment that has arrived for a resident. Outside agency notes to be reviewed within 24 hours for possible changes need to the service plan.

Outside agency notes to be reviewed daily, noted in chart notes and interim service plan put in place to notify staff of any changes.

Daily

RCC and Executive Director

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and fire drill records included documentation of all required elements. Findings include, but are not limited to:

Fire drill records were reviewed from 11/2021 through 04/2022. Documentation indicated that no residents were relocated during the fire drills, preventing the facility from documenting the following required elements:

* Escape route used;

* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and

* Number of occupants evacuated.

The need to ensure fire drills were conducted according to the Oregon Fire Code (OFC) and included documentation of all required elements was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 05/04/22. They acknowledged the findings.

Training/Review with Maintance Director 5/13/2022

on Fire Drill Rule stating residents within the zone of the drill must attempt to be evacuated/relocated. Training at all staff metting done 5/20/2022

During Fire Drills all residents within the zone of the drill will be asked to evacuate/relocate from their apartment or common area to a safe zone outside of the drill.

At time of each drill.

Maintenance Director and Executive Director.

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

Fire and life safety records were reviewed from 11/2021 through 04/2022. The following deficiencies were identified:

* The facility failed to provide residents with accurate instructions for how to respond during a fire or fire drill, and failed to have a process for documenting that fire and life safety training was reviewed with residents at least annually.

The need to ensure residents were instructed in accurate fire and life safety procedures upon admission and at least annually, was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director). They acknowledged the findings.

Resident Handbook updated with instructions on how to respond during a fire drill. Service plan updated to reflect same instructions as handbook. Copies of handbook revision to be handed out at resident council  and/or delivered to resident apartment if not at council meeting.

Resident Handbook to be given to all new residents at move in, with signature page verifying they have received and understand contents. RCC to review procedure at all service plan meetings, quarterly and/or change of condition.

At Admit and at time of quarterly review, change of condition reviews.

Administrative Assistant and Executive Dierctor.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The facility was toured on 05/02/22. Resident unit windows on the second and third floors, and some of the first floor which was elevated due to the slope of the property, slid open horizontally and windowsills were lower than 36 inches. The windows lacked a system which limited how much the window could be opened to prevent accidental falls.

The lack of a mechanism to prevent accidental falls from windows that were above the first floor was discussed with Staff 1 (Administrator) and Staff 4 (Maintenance Director) on 05/03/22. They acknowledged the findings.

Maintenance staff to check all windows above 36 inches from the ground to ensure windows are designed to prevent accidental falls.

Maintenance staff to secure all windows higher than 36 inches above the ground to not open wider than 3 inches.

Weekly, on housekkeping day.

Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) or a chemical disinfectant was used when washing residents' soiled linens and clothing, and that the facility stored and handled soiled laundry separately from regular linens and clothing. Findings include, but are not limited to:

During a tour of the facility, washers were noted to lack a hot water rinse setting. The laundry detergent observed in the laundry room did not contain a disinfecting agent. There were several large black garbage bags full of clothing and linens on the floor of the laundry room - not all bags were sealed.

In an interview on 05/03/22, Staff 4 (Maintenance Director) confirmed the washing machines did not have a rinse temperature of 140 degrees F. He stated the facility either used a resident's personal laundry detergent or the detergent that was observed during the tour.

In separate interviews on 5/4/22, Staff 9 (CG) and 12 (CG) both reported housekeeping staff normally took care of resident laundry but caregivers had been helping recently. Staff 9 reported sometimes staff failed to separate soiled laundry items from regular resident laundry when they bagged the items, and acknowledged sometimes garbage bags were not tied shut. Staff 9 confirmed soiled laundry was washed using the laundry detergent observed in the laundry room.

The facility's failure to properly handle and launder soiled resident linens and clothing was reviewed with Staff 1 (Administrator) and Staff 7 (RN Consultant) on 05/04/22. They acknowledged the findings.

Facility has switched laundry detergents to a powdered detergent/disinfectant.

All staff training on proper bagging and separating of linens/clothing that are soiled.

All soiled linens/clothing will be bagged and labeled separately, will then be washed separately with the powdered detergent/disinfectant. Laundry personel will notify supervisor if laundry is not being separated and labeled correctly.

Weekly

Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit (F) when they are installed in locations that are subject to incidental contact by individuals or with combustible material. Findings include, but are not limited to:

During a tour of the building on 05/02/22, wall-mounted baseboard heaters were observed in multiple resident one- and two-bedroom units. The heaters were located where residents could fall against them. When a heater was turned on it felt hot to the touch, even at the lowest thermostat setting. The top surface temperature of the baseboard heaters in multiple rooms was measured with the surveyor's digital thermometer and found to range from 124 - 135 degrees F.

A cadet-style wall heater was observed in the Spa Room on the third floor of the building. When the heater was turned on, the temperature of the lower part of the metal grate was found to quickly climb to 200 degrees F.

The heaters were discussed with Staff 4 (Maintenance Director) on 05/03/22 at 11:00 am. He acknowledged one- and two-bedroom resident units had baseboard heaters and confirmed he had replaced the heater in the Spa Room because it had not been working. He stated he was not aware surface temperatures could not exceed 120 degrees F.

The heaters were discussed with Staff 1 (Administrator) on 05/03/22 at 11:50 am. She acknowledged the heaters were not in  compliance with the rule. Since the resident units also had an alternative heating source and residents were not using the baseboard heaters at this time of year, an immediate plan of correction was not requested by the survey team. On 05/04/22, Staff 1 asked Staff 7 (RN Consultant) to review the heater in the Spa Room with the surveyor. The surveyor and Staff 7 again verified the surface temperature to be in excess of 200 degrees F. Staff 7 said she would have the heater immediately disconnected.

Maintenance staff will test all baseboard heaters to ensure heaters do not exceed 120 degrees.

Cadet heater in 3rd floor bathroom has been disconnected as it is not used.

Heaters not in use will be disconnected, heaters rising above 120 degrees will be covered with a heater guard.

Weekly, on housekeeping day.

Maintenance Director