The findings of the re-licensure survey, conducted 12/06/21 through 12/09/21, 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 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 re-visit to the re-licensure survey of 11/09/21, conducted 02/09/22 through 02/10/22 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, and the OARs 411 Division 004 Home and Community Based Services Regulations.

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

A tour of the kitchen was conducted on 12/06/21 and revealed the following:

* Wooden cupboards had dings, dents and gouges creating uncleanable surfaces;

* Walls throughout the kitchen had a brown residue on them; and

* Wall next to the dry storage had clumps of dust and spider webs on them.

The need to ensure the kitchen was clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000 was discussed with Staff 1 (Administrator). She acknowledged the findings.

1) There were no specific resident examples mentioned in this violation.  The following will be completed to correct the violation in the Kitchen:

A) The dings, dents and gouges in the wooden cupboards and wooden drawers will be repaired and re-painted to create cleanable surfaces.

B) The wall areas throughout the Kitchen will be cleaned to remove the brown residue and re-painted as necessary to create clean surfaces.

C) The wall next to the dry storage will be cleaned to remove the clumps of dust and spider webs on it.

2) A regular weekly kitchen cleaning schedule has been implemented for dietary staff to follow and complete.  We will also continue to utilize our current work order request system for staff to complete and turn in to Maintenance for any maintenance related items/repairs needing attention.

3) Cleaning schedules will be monitored, evaluated and reviewed on a weekly basis for completion.  The Maintenance work order request system is monitored and reviewed and evaluated daily.  

4) Administrator and/or designees will be responsible for ensuring completion of corrections and ongoing moitoring for compliance.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and failed to complete an evaluation to determine a resident's ability to safely smoke independently for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 9/2021.

Resident 1's move-in evaluation failed to address the following:

* Customary routines for sleeping and bathing;

* Spiritual, cultural preferences and traditions;

* List of medications and PRN use;

* Vital signs if indicated by diagnosis, health problems or medications;

* Presence of depression, thought disorders or mood problems;

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

* Hearing, vision speech and assistive devices;

* Dental status and assistive devices;

* Ability to use call system;

* Fluid preferences;

* Indicators of nursing needs including potential for delegated nursing tasks;

* Fall risk and history;

* Smoking, ability to smoke safely;

* Emergency evacuation ability;

* Complex medication regimen;

* History of dehydration or unexplained weight loss or gain;

* Unsuccessful prior placements; and

* Pharmaceutical and non-pharmaceutical interventions including how the person expresses pain or discomfort.

The need to ensure the move-in evaluation addressed all required elements and the need to evaluate residents for the ability to safely smoke independently was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

A smoking evaluation was completed on resident #1 and the service plan was updated.

A new move-in evaluation tool has been adopted.

Service plans and assessments will be evaluated and updated quarterly and/or as needed to ensure accuracy.

The RN and RCC are responsible for monitoring and updating the service plans and assessments.

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

1. Observations of Resident 2, interviews with the staff and review of Resident 2's most recent service plan dated 11/03/21 indicated the service plan was not reflective and/or lacked clear direction to staff in the following areas:

* Use of Ted Hose; and

* Transfer assistance and assistive devices

Observations of Resident 2 on 12/09/21 revealed s/he was not wearing Ted hose while sitting in his/her wheelchair.

Interview with Staff 12 (CG) on 12/09/21 revealed Resident 2 did not have Ted Hose in the building and wasn't sure where they were since s/he still uses them. Staff 12 indicated the staff transfer Resident 2 by pivot transfer using a gait belt.

In an interview with Staff 3 (RCC) on 12/09/21, she was unaware the staff were transferring the resident using a gait belt and provided an order discontinuing his/her Ted hose.

2. Interviews with Resident 1 and facility staff and review of Resident 1's most recent service plan dated 10/21/21 revealed the service plan was not reflective and/or lacked clear direction to staff in the following areas:

Interview with Resident 1 on 12/08/21 showed s/he occasionally liked to go to the bar or buy a bottle of liquor at the store.

Interview with Staff 6 (MT) on 12/08/21 revealed Resident 1 on occasion would go to the bar or buy a bottle of alcohol and become intoxicated. When s/he was intoxicated, s/he required ambulation, dressing and transfer assistance.

Review of Resident 1's most recent service plan dated 10/21/21 did not reflect the extra assistance the facility provided when s/he was intoxicated.

Interview with Staff 1 (Administrator) and Staff 11 (Administrator in training) on 12/08/21 showed Staff 1 did not think the service plan needed to reflect this care because it doesn't happen on a regular basis. Staff 11 confirmed the services should be added onto the service plan if the facility is providing the assistance.

The need to ensure service plans were reflective of resident's current care needs and provided clear direction to staff was discussed with Staff 1 and Staff 11 on 12/09/21. They acknowledged the findings.

Resident #2's service plan was reviewed to reflect dcurrent current transfer status. Her PCP reinstated the use of ted hose. Service was updated.

Resident #1 service plan was updated to reflect increased care needs when intoxicated.

Service plans and assessments will be evaluated and updated quarterly and/or as needed to ensure accuracy.

The RN and RCC are responsible for monitoring and updating the service plans and assessments.

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 2 of 4 sampled residents (#s 3 and 4) who had documented medication and treatment refusals. Findings include, but are not limited to:

Resident 1's December 1st through 6th 2021 MAR was reviewed during the survey. The resident refused his nicotine patch on 12/04/21, 12/05/21, and 12/06/21. There was no documented evidence the facility notified the physician of the medication refusals.

In an interview with Staff 2 (RN) and Staff 3 (RCC) on 12/07/21, revealed the facility was unaware of the rule to notify resident's physicians of medication refusals.

The need to ensure the facility notified physicians of medication and treatment refusals for each time the resident refused to consent to orders was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 on 12/08/21. They acknowledged the findings.

Resident #1's provider was notified of his refusals of medication.

The RN or RCC will review the MAR for any medication refusals one day a week and the provider will be notified.

The provider will be notied weekly of medication refusals.

The RN and RCC will be responsible for monitoring and assuring communicaiton with the provider.

Based on interview and record review, it was determined the facility failed to employ a full-time Administrator scheduled to be on-site at least 40 hours per week. Findings include, but are not limited to:

During the acuity interview on 12/06/21, Staff 1 (Administrator) reported she was the Administrator for the Nursing Facility upstairs in addition to being the Administrator in the RCF.

Staff 1 acknowledged she did not spend 40 committed hours a week in the Residential Care Facility.   

1) There were no resident examples for corrections to this violation.

2) Myrtle Point Care Center has submitted a request for a Shared Administrator Waiver to OAR 411-054-0065 (1).

3)  The waiver will be evaluated and reviewed for ongoing compliance annually.

4) Administrator will be responsible for review and monitoring of Waiver compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff  (#7, 9 and 10) completed first aid/abdominal thrust training within 30 days of hire.  Findings include, but are not limited to:

Review of staff training records on 12/08/21 revealed the following:

Staff 7 (CG), Staff 9 (CG) and Staff 10 (CG) did not have documented evidence of completion of first aid/abdominal thrust training within 30 days of hire.

The need to ensure all newly hired staff completed first aid/abdominal thrust training within 30 days of hire was discussed with Staff 1 (Administrator) on 12/08/21. She acknowledged the findings.

Staff 7, 9 and 10 have been trained in first aid/abnominal thrust.

We will ensure that new hires are trained in first aide/abdominal thrust.

Each new hire will be trained in first aide/abdominal thrust within 30 days of hire.

Administrator or designee will ensure each new hire has competed first aid/abdminal thurst training.

Based on interview and record review, it was determined the facility failed to ensure fire drills included all required components and failed to provide fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

Review of fire drill records dated 05/01/21 through 12/07/21 revealed fire drills did not include all required components and there was no documented evidence fire and life safety training was being provided to staff on alternating months.

* Escape route used;

* Alternate escape routes used; and

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills.

The need to ensure the facility included all required components of fire drills and provided fire and life safety instruction to staff on alternating months was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1) There were no resident specific examples given for violation of this rule to correct. The current fire drill record form that facility uses was reviewed and will be modified to include areas for documentation of required components such as:

A) Escape route used

B) Alternate escape route used

C) Problems encountered during drill, comments relating to residents who resisited or failed to participate in drill

Fire and LIfe Safety  education/instruction to staff will take place at monthly held All-staff meetings. Fire/Life Safety trainings will be documented utilizing existing staff inservice sign in attendance sheets with topic of training and any handouts /discussion attached.

2) Facility will start utilizing the new/modified version of the fire drill form starting with scheduled fire drill in January 2022.

Fire and LIfe Safety training with documentation will begin with All-staff meeting scheduled for or around January 10, 2022.

3) Fire drills will continue  to he held monthly per our existing fire drill schedule.

Fire and LIfe Safety training for employees will be held at least every other month at All-Staff meetings beginning with scheduled All-Staff meeting on or around January 10, 2022.

4) Administrator or designee will be responsible to ensure that modified fire drill record is used accurately to ensure compliance.

Maintenance Director will be responsible for training of Fire/Life Safety topics at all-staff meetings to ensure compliance.   

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

A tour of the facility with Staff 1 (Administrator) 12/07/21 revealed the following deficiencies:

* Throughout the facility, there were dings, dents and scratches on the walls;

* Multiple resident room doors had chipped paint;

* Resident doors without protective plate had glue stains on them; and

* Door frames throughout the facility had dings, dents and scratches.

The need to ensure the interior materials and surfaces were kept clean and in good repair was discussed with Staff 1 on 12/07/21. She acknowledged the findings.

1) There were no specific resident examples to correct for this violation.  Administrator and Maintenance Director reviewed areas of the facility where deficiencies exist. Maintenance Director will repair, clean, sand down and re-paint deficient areas as needed to ensure surfaces are clean and in good repair such as:

A) Dings,dents and scratches on various walls

B) Chipped paint on multiple resident room doors

C) Removing/repairing glue stains on resident doors without protective plates.  Will also be adding protective plates to resident doors that have no protective plates currently.

D) Dings, Dents and scratches on multiple door frames

2)  A preventative maintenance schedule will be utilized to review and ensure interior materials and surfaces are kept clean and in good repair

3) The preventative maintenance schedule will be set up for monthly reviews and follow through to ensure compliance.

4) Maintenance Director will be responsible for performing monthly preventative maintenance schedule reviews and completing any repairs necessary.  Administrator or designee will monitor preventative maintenance schedule for completed repair tasks to ensure compliance.

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

On 12/07/21, the surveyor tested the temperature of wall heaters with Staff 4 (Maintenance Director) in multiple resident rooms. In Resident room 37, the temperature reached 137.2 degrees F. In Resident room 40, the temperature reached 141 degrees F. In an interview with Staff 4, all the resident rooms had the same wall heaters.

Staff 4 showed the surveyor a ceramic heater in the medical records room which was cool to the touch when turned on. His plan was to get a quote and replace all wall heaters with this new ceramic heater.

The need to ensure the surfaces of the wall heaters did not exceed 120 degrees F was discussed with Staff 1 (Administrator) on 12/07/21. She acknowledged the findings.

1) Facility will have heat shields fabricated and installed that will cover the portion of the heaters, in resident rooms #37 and #40, that become warm to the touch.  The heat shields will be temperature checked to ensure compliance.  

2) The Facility will also have heat shields fabricated and installed that will cover the portion of the heaters that become warm to the touch for the other resident rooms in the facility that have the existing heaters in violation of this rule.

3) Testing of temperatures of the heaters with the heat shields will be put on the preventative maintenance schedule to do documented temp checks on heaters weekly.

4)Maintenance Director will be responsible to conduct the temperature checks on heaters and document appropriately to monitor for compliance.