The findings of the initial survey, conducted 08/29/22 through 08/30/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 initial survey of 08/30/22, conducted 12/29/22, 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, OARs 411 Division 57 for Memory Care Communities.

Based on observation, interview and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the MCC was home to nine residents.   

Random resident observations made on 08/29/22 and 08/30/22, review of the activity calendar, and interviews with staff revealed the following:

a. The August 2022 Memory Care Activity Program calendar posted in the facility indicated the following activities would occur on 08/29/22:

* 10:00 am - 11:00 am: Background Music; and

* 2:00 pm - 3:00 pm: Water Painting.

On 08/29/22, the only facility led activity observed occurred at approximately 1:30 pm, when one resident was observed painting at a dining room table. Although television and music played continuously, no other activities were observed between 9:30 am and 3:30 pm.

b. On 08/30/22, the activity calendar noted the following activities would occur:

* 2:00 pm - 3:00 pm: Live Music.  

The only facility led activities observed between 8:30 am - 2:00 pm were a musical performance from a visitor between 11:00 am and 12:00 pm.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Owner) and Staff 1 (RN/Administrator) on 08/30/22 at 2:35 pm. They acknowledged the findings.

Our Policies and tools we have in place to assure a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs are in accordance with the regulations and do not need updating at this time.

However, this Facility is in process of hiring new Activity Director to ensure a daily program of social and recreational activities are provided and maintained.

The Activities Program/Schedule will be verified by Facility Owner on a weekly basis.

The Facility Owner is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure hot water temperatures in residents' units and common bathrooms were maintained within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

On 08/30/22, the surveyor measured water temperatures in occupied residents' unit bathrooms including Rooms 3 and 10 and a common bathroom in the facility. Water temperatures measured were between 90 to 113 degrees Fahrenheit.

On 08/30/22 at 1:50 pm, the surveyor informed Staff 3 (Maintenance Director) of the low-water temperatures. The surveyor and Staff 3 measured water temperatures in Room 10, using the surveyor's thermometer. The temperature reached 104 degrees Fahrenheit. Staff 3 stated he was aware of the findings and said he would inform Staff 1 (Owner) of the issue.

On 08/30/22 at 2:35 pm, the low water temperatures were discussed with Staff 1 (Owner) and Staff 2 (Administrator/RN). They acknowledged the findings.

Facility has attended to this dificiency immediately by contacting the landlord and making them aware of this issues and informed of urgency for hot water temperatures to be brought up to the building codes.

Landlord scheduled services for additional pump to be installed to unit, that will cycle the hot water in order to assure the water temperature is maintained within a range of 110-120 degrees Fahrenheit.

The Maintenance Director will meassure water temperatures monthly, in random units and Resident's Rooms to verify water temperaures are maintained within a range of 110-120 degrees Fahrenheit and will report to the Facility Owner.

Facility Owner is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable systems for security purposes and to alert staff when residents exited the unit. Findings, include, but are not limited to:

During the survey, the facility was identified to have a couple of exit doors, accessible to the secured courtyard.

On 08/30/22 at 9:15 am, a tour of the facility with Staff 1 (Owner) revealed the doors failed to have a working alarm device to alert staff when residents exited the unit.

On 08/30/22, the lack of alarms or other acceptable system was shared with Staff 1. She confirmed there was no system to alert staff when residents exited the unit.

Facility has attended to this difficiency immediately by installing alarming devices on both exit doors accessible to the secured courtyard.

These alarms provide a beeping sound each time a Resident exits any of the two doors, to access the secured courtyard, alerting the staff that a Resident is outside.  

The Facility Owner will verify functionality of the alarming devices installed on all exit doors periodically, at random times.

The Facility Owner is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C242, C545 and C555.

This Facility took note of all dificiencies listed in the Statement of Deficiencies and a Plan of Correction was established which will be fully impemented no later than 10/29/2022.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly hired staff (#s 3 and 6) completed all required pre-service training prior to performing any job duties. Findings include, but are not limited to:

Staff training records were reviewed on 08/30/22. The following deficiencies were identified:

1. Staff 3 (CG/Maintenance) was hired 05/07/22.

a. There was no documented evidence he had completed the following elements of the required pre-service orientation prior to performing any job duties:

*Infectious Disease Prevention.

2. Staff 6 (CG) was hired 04/06/22.

There was no documented evidence she had completed the following elements of the required pre-service orientation and dementia training prior to performing any job duties:

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

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

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

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

* 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;

* Environmental factors that are important to a resident's well-being (e.g. staff interactions, lighting, room temperature, noise, etc.)

* Family support and the role the family may have in the care of the resident;

* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

The need to ensure newly hired staff completed all required orientation and pre-service training was discussed with Staff 1 (Owner) on 08/30/22 at 12:20 pm. She acknowledged the findings.

The policies and tools we have in place to ensure that all staff training requirements are met are in accordance with the regulations and do not need updating at this time.

However we have re-educated our staff on the importance of completing all required trainings such as the pre-service Dementia care training and pre-service  infection control and prevention training, prior to providing care to Residents.

Staff 3 and Staff 6 immediatelly and effectively initiated completion of the missing trainings.

Facility Owner and Facility Administrator will review every new-hire and will ensure all Caregivers have all the required trainings prior to initiating/providing care.

Facility Owner and Facility Administrator are responsible for this plan of correction.  

Based on observation and interview, it was determined the facility failed to ensure the fence surrounding the perimeter of the outdoor recreation area was fully secured, and to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but not limited to:

1. During a tour of the environment with Staff 3 (Maintenance Director) on 08/30/22, one of the secured outdoor recreation areas was observed. The area revealed the perimeter fence was not fully secured and fenced. The corner of the outdoor recreation area had no fence, but an unsecured bamboo screen and large bush/plant was in place.

On 08/30/22, the need to ensure the fence surrounding the perimeter of the outdoor recreation area was fully secured was discussed with Staff 1 (Owner), Staff 2 (Administrator/RN) and Staff 3. They acknowledged the findings.

2. During the survey, the doors to the interior courtyard were observed to be unlocked during daylight hours and there was no device to lock the doors during nighttime hours or during severe weather.

On 08/30/22 at 9:15 am, the surveyor requested the facility's written facility policy regarding the operation of the doors. Staff 1 (Owner) stated the facility did not have a written policy for when the courtyard doors would be locked.

On 08/30/22 at 2:35 pm, the above findings were shared with Staff 1 and Staff 2 (Administrator/RN). They acknowledged the findings.

Facility attended to this dificiency immediately by contacting landlord and making them aware of this issue and informing of urgency for fence surrounding the perimeter of the outdoor recreation area be fully secured and brought up to codes.

Landlord scheduled services for specified section of fence to be replaced and secured.

The facility also contacted the landlord regarding the doors to the interior courtyard and made aware of urgency for locks to be installed on both these doors in order to be brought up to building codes. Landlord scheduled services for locks to be installed on the two specified doors.

The facility built a written policy regarding the operation of these doors, which will reflect when the doors accessing the secured recreational area will be locked for Resident's safety, as well as who will be responsible to implement the guidelines written in this policy.

Facility Owner will review and make changes to this policy as needed and will verify randomly, at different times, with different shifts, to make sure the policy is implemented.

Facility Owner is responsible for this plan of care.

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked inside or outside their rooms, and to individually identify residents' rooms to assist residents in recognizing their rooms.  Findings include, but are not limited to:

1. During the survey, observations revealed several resident rooms were locked from the outside. Caregiving staff each carried a key which could open all residents' doors.

On 08/30/22 at 11:25 am, Staff 9 (CG) stated the facility kept resident doors locked because some residents wandered the facility, entering other resident rooms. However, this rendered residents unable to get into their rooms without staff assistance.

On 08/30/22 at 2:35 pm, the requirement that residents could not be locked out of their rooms was shared with Staff 1 (Owner) and Staff 2 (Administrator/RN). They acknowledged the findings.

2. The facility was toured on 08/30/22. Residents' rooms 4, 5, 6, 7, 8, 9, 10, 11 and 12 lacked any means of identifying the rooms for the residents.

On  08/30/22, the need to ensure each resident room was identified to assist the resident in identifying their room was reviewed with Staff 1 (Owner) and Staff 2 (Administrator/RN). They acknowledged the findings.

Our policies and tools we have in place to ensure residents are not locked inside or outside of their rooms, and to individually identify their rooms and to assist residents in recognizing their rooms, are in accordance with the regulations and do not need updating at this time.

However, we have reeducated our staff and reenforced that every Resident should be able to enter and/or exit their rooms without requiring any assistance from staff.  We reeducated our staff that even with behaviors of wandering in the facility, locking rooms in order to keep rooms tidy is not allowed and against the facility policy and against regulations.

Facility Owner will verify this weekly at random times and different shifts, for the next quarter, then will continue verifying monthly at random times and different shifts.  

Facility had previously applied framed pictures by Resident's doors, but these have been removed by wondering Residents.

Facility Owner applied new framed pictures on Resident's doors and secured them to prevent removal by wondering Residents. We also applied on some Resident's doors stickers with images that they can easily identify with, to assist them with identifying their rooms.

Facility Owner will verify each Resident's room has identification in place at the door, on a quarterly basis.

Facility Owner is responsible for this plan of correction.