The findings of the re-licensure survey conducted 07/22/24 through 07/25/24 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 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
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 07/25/24, conducted 11/12/24 through 11/14/24, 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 for Home and Community Based Services Regulations.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag Numbers beginning with H refer to the 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 second re-visit to the re-licensure survey of 07/25/24, conducted 02/03/25, 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 OARs 411 Division 004 Home and Community Based Services Regulations.
2. Resident 4 was admitted to the facility in 05/2016 with diagnoses including glaucoma, depression and athersclerotic heart disease.
Review of the resident's record, including progress notes, the service plan, Interim Service Plans (ISPs) and incident reports, indicated the following issues:
a. On 06/22/24, the resident pushed his/her call light and was found on the floor in his/her apartment bathroom. The facility immediately provided written instructions to staff to implement monitoring each shift for subsequent pain or injuries. However, the facility did not document a follow up until 07/01/24 and the documentation did not indicate the facility monitored whether the existing service-planned fall interventions were effective in preventing further falls or whether additional interventions needed to be developed and implemented.
b. On 07/07/24, Resident 4 triggered for a severe weight loss over the previous 30 days. The facility RN immediately assessed the resident's condition and wrote orders for:
* A nutritional drink to be provided twice daily between breakfast and lunch, and between dinner and bedtime; and
* Additional nutritional drinks as requested by the resident.
During the survey, it was observed that staff were providing the drink with breakfast, but not between breakfast and lunch as ordered. The resident's weight on 7/24/24 was the same as the weight documented on 07/07/24.
The facility failed to monitor whether the new interventions developed to address the resident's weight loss were being followed and were effective.
The need to monitor a resident consistent with his/her evaluated needs and service plan was reviewed with Staff 1 (ED), Staff 2 (RN) Staff 3 (RCC) and Witness 1 (Consultant) on 07/25/24. They acknowledged the findings.
3. Resident 5 was admitted to the facility in 07/2021 with diagnoses including dementia.
Review of the 04/21/24 through 07/22/24 progress notes, Outside Provider Notes, 01/11/24 service plan, and Temporary Service Plans (TSP's) revealed on 06/30/24, Resident 5 was noted to have experienced "a very minor stage two pressure sore: very small skin tear on [his/her] coccyx." The resident was receiving treatments triweekly and PRN for the skin condition.
The facility lacked documented evidence the skin condition was monitored, with progress noted at least weekly through resolution.
The need to ensure progress was documented at least weekly until resolution for Resident 5's skin condition was discussed with Staff 1 (ED), Staff 2 (RN), Staff 3 (RCC) and Witness 1 (Consultant) on 07/25/24. They acknowledged the findings.
Based on observation, interview, and record review, it was determined the facility failed to determine what resident-specific action or intervention was needed for a resident following a short-term change of condition, communicate the determined action or intervention to staff, document weekly progress until the condition resolved, and monitored the resident consistent with their evaluated needs and service plan, for 3 of 4 sampled residents (#s 1, 4 and 5) who experienced changes of condition. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic congestive heart failure, and major depressive disorder.
Clinical records, including the current service plan, dated 04/18/24, and progress notes from 04/21/24 through 07/20/24 were reviewed, and interviews with facility staff were conducted.
The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, and communicated the determined action or intervention to staff:
07/20/24: Progress note recorded "Resident ...reported that [s/he] stepped wrong and tweaked right ankle."
The need to ensure the facility evaluated the resident and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition and communicated the determined action or intervention to staff was reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 (RCC) on 07/25/24. They acknowledged the findings. No further information was provided.
The community will take the following actions to correct C270:1. Resident #1 will be reassessed for a change of condition, and her service plan will be updated accordingly to reflect this change. Resident #2 will be reassessed to ensure her service plan addresses her change of condition due to weight loss and fall. The resident's nutritional supplement is noted in the current service plan and placed on MAR for 1000 and 1700. It will be signed off when given.
Resident #5's service plan will be reviewed to integrate outside provider notes, and the community nurse will perform weekly skin checks to monitor it.
2. Community RN will attend CBC nursing training through OHCA to ensure adherence to change of condition regulations, and staff will be in-serviced on proper documentation and follow-up for a change of condition. Assisted Living administrator will also review the 24-hour report for any progress notes that would trigger COC.
3. All changes in condition will be reviewed in a weekly clinical meeting with nursing staff and the administrator.
4. The Assisted Living Administrator and community RN will share the responsibility for the completion and monitoring of the change of condition process.
There are no detail notes for this visit.
2. Resident 2 was admitted to the facility in 11/2022 with diagnoses including intracranial injury, neck fracture, hemiplegia and hemiparesis of non-dominant side and dysphagia.
Review of the most recent signed physician orders found in the resident's record, dated 06/27/24, and subsequent orders indicated the following discrepancies with the 07/01/24 through 07/22/24 MAR:
* There was an order for olopatadine 0.1% eye drops (for eye irritation): 1 drop in right eye twice daily; the MAR read to administer 1 drop in both eyes twice daily.
* The 06/27/24 physician orders included an order to discontinue Resident 2's routine twice-daily Seroquel (for agitation). The MAR indicated the facility had continued to administer the medication twice daily between 07/01/24 and 07/21/24.
The need to ensure medications were administered as prescribed and the facility had an effective system for reviewing new orders was reviewed with Staff 1 (ED), Staff 2 (RN) Staff 3 (RCC) and Witness 1 (Consultant) on 07/25/24. They acknowledged the findings. Staff 2 and Staff 3 immediately clarified the orders and corrected the MAR.
Based on interview and record review, it was determined the facility failed to ensure physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 5 sampled residents (#1 and 2) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 1 was admitted to the facility in 09/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic congestive heart failure, and major depressive disorder.
Review of Resident 1's current physician orders and MAR from 06/01/24 through 07/22/24 revealed the following:
* Physician order dated 06/05/24 stated "Change torsemide to 40 mg twice a day. If your weight increases by 3 lbs, take 1 extra torsemide around 2 pm." There was no documented evidence additional torsemide was administered as ordered from 06/06/24 through 06/10/24, during which time daily weights were more than 3 lbs above the goal weight of 182 lbs;
* Physician order stating "If your weight increases by 3 lbs above 182 lbs, take 1 extra torsemide" was discontinued on 06/12/24. According to the MAR, an extra dose of torsemide was administered on 06/23/24 and from 06/28/24 through 06/30/24; and
* Physician order dated 06/12/24 ordered torsemide 20 mg to be administered three tablets by mouth two times a day. According to the MAR, torsemide 20 mg was administered two tablets by mouth once a day on 06/13/24.
The need to ensure physician or other legally recognized practitioner orders were carried out as prescribed was reviewed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (RCC) on 07/25/24. They acknowledged the findings. No further information was provided.
The community will take the following steps to correct C303:
1. Resident #1's order for Torsemide has been changed to x2/day, and the PRN order has been d/c'd, allowing for clarity of medication delivery. Should the resident's weight change, the physician will be notified.
Resident #2 passed away in hospice on 8/1/2024
2. All new orders go through a triple-check system from med tech to RCC to RN. RCC will flag orders that require clarification to ensure safe delivery. Additionally, all hospice providers will be notified and educated that new and updated orders must be given in the form of an actual physician order so as not to get lost in translation.
3. New hospice medication orders and/or flagged orders will be reviewed in the RN's third check. The community pharmacy will provide quarterly chart/mar cart audits, with the next one scheduled for 8/28/2024.
4. The RN, AL Administrator, or designee will monitor medication orders and MAR accuracy.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents' ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled residents (# 1) who was reviewed for self-administration. Findings include, but are not limited to:
Resident 1 was admitted to the facility in 09/2019 with diagnoses including chronic obstructive pulmonary disease (COPD), chronic congestive heart failure, and major depressive disorder.
During the acuity interview on 07/22/24, Resident 1 was not identified as self-administering any of his/her medications. However, review of Resident 1's MAR on 07/22/24 revealed s/he was self-administering (genital) cream Estradiol 0.01%, and during the interview on 07/23/24 with the resident, s/he indicated s/he was administering oxygen as needed overnight for shortness of breath. This was confirmed by Staff 11 (MT) in an interview on 07/23/24.
Review of Resident 1's medical records revealed there was no documented evaluation of Resident 1's ability to safely self-administer medications, and no physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was given. In an interview on 07/24/24, Staff 2 (RN) acknowledged no physician or other legally recognized practitioner's written order was available, and Staff 2 was unable to locate a copy of the self-administration evaluation.
The need to ensure residents who chose to self-administer their medications were evaluated upon move-in and at least quarterly thereafter to assure the residents' ability to safely self-administer medications and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was reviewed with Staff 1 (ED), Staff 3 (RCC) and Staff 2 on 07/25/24 at 2:40 pm. They acknowledged the findings. No further information was provided.
The community will take the following actions to correct C325:
1. Resident #1 will receive an updated self-administration of medication for the two noted medications and an updated physician's order to self-administer.
2. The community will audit current AL residents with self-administration orders and ensure assessments and physician orders are current.
3. Residents with self-administration assessments and orders will be reviewed quarterly during their service plan review or with any change of condition to ensure they can still safely continue with self-administration.
4. The AL Administrator, RN, or designee will monitor and ensure compliance.
Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications or treatments had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 2 of 2 sampled residents (#s 7 and 8) who were reviewed for self-administration. This is a repeat citation. Findings include, but are not limited to:
During the acuity interview on 11/12/24, Residents 7 and 8 were identified to self-administer some or all of their prescribed medications.
Review of the clinical records, including current physician orders for Residents 7 and 8, identified the physicians had not given written orders authorizing either resident to self-administer their own prescribed medications.
The need to ensure residents who chose to self-administer their own prescribed medications or treatments had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications was discussed with Staff 16 (RCC), Staff 17 (LPN/Associate Health Services Director) and Staff 20 (Memory Care Director/Designee) on 11/14/24 at approximately 11:00 am. They acknowledged the findings.
1.Community has faxed pcp orders for self medicaction administration orders for Residnet 7 and resident 8 . PCP orders have both been received, signed and noted ok to administer self medication for residnet 7 and 8. Residnets Mar and careplans have been updated with the correct information to refect self medication admistration. Medication tech's and clinical team will be completing a training on new tripple check process and self medication administration evaluations on 11/12/24 .
2.All residents have been audited and added to quarterly evauation list for LPN to evaluate at each quarter as careplans are due. A fax to the PCP will be sent off as the quarterly evaluations are due. PCP orders will be processed through the communties new tripple check process that requires review and signatures from 1.Medication tech 2.Medication tech #2 3. License nurse. Med techs will review and process orders daily.
3.Licence nurse and Executive director will review quarterly evaluations for self medication administration each quarter and as needed for changes at each careplan date.
4.Executive Director
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to accurately identify the amount of time required to complete ADLs for 4 of 4 sampled residents (#s 1, 2, 4 and 5) and use the results of an acuity-based staffing tool (ABST) to develop and routinely update the facility's staffing plan to meet the 24-hour scheduled and unscheduled needs of residents. Findings include, but are not limited to:
a. During the survey, records for Residents 1, 2, 4 and 5 were reviewed, residents and caregiving staff were interviewed and care services were observed.
Resident 1, 2, 4 and 5's individual ABST evaluations were inaccurate on one or more of the following ADL elements:
* Monitoring physical conditions or symptoms;
* Monitoring behavioral conditions or symptoms;
* Ensuring non-drug interventions for behaviors;
* Repositioning in bed or chair;
* Ambulation, escorting to and from meals or activities;
* Responding to call lights
* Supervising, cueing, or supporting while eating;
* Safety checks, fall prevention;
* Assisting with communication, assistive devices for
hearing, vision, speech;
* Assisting with leisure activities;
* Cueing or redirecting due to cognitive impairment or
dementia; and
* Completing resident specific housekeeping or laundry
services performed by care staff.
b. During the survey, it was observed that care staff often brought residents to lunch up to 30 minutes after lunch began. In interviews on 07/23/24 and 07/24/24, Staff 6 (CG) and Staff 7 (CG) reported they were not able to consistently get residents up and ready in the morning or get residents to lunch timely because there were not enough staff scheduled. In an interview on 07/23/24, Staff 9 (MT) reported that not having enough staff scheduled on evening shifts sometimes resulted in a slower staff response to call lights. In an interview on 07/25/24, Staff 7 reported s/he was unable to provide Resident 4 with his/her scheduled shower that shift.
c. On 07/25/24, the facility's ABST and process for using the results to develop a staffing schedule was discussed with Staff 1 (ED), Staff 3 (RCC) and Witness 1 (Consultant). The ABST showed that, at a minimum (the lowest value of the week), residents during day shift required 31.36 hours of care. The facility confirmed it was currently scheduling four staff (two CGs and two MTs) on day and evening shifts, and that each shift was 8 hours in length. Allowing for 30 minutes for a lunch break, each worker provided 7.5 hours of care per shift; this equated to 30 total hours of scheduled caregiving time for the shift. They acknowledged this was below the 31.36 hours, and identified that they had not allowed for lunch breaks when calculating how many staff were needed.
The need to ensure the evaluation of time needed to provide resident care was accurate and that the facility used the results of the ABST to correctly develop a staffing schedule was reviewed with Staff 1, Staff 2 (RN), Staff 3 and Witness 1 on 07/25/24. They acknowledged the findings.
The community will take the following actions to correct C361:
1. Residents 1, 4, and 5 will all be reassessed, and their ABST will be updated to reflect their updated assessments.
Resident #2 passed away in hospice on 8/1/2024.
2. The community will review all minutes assigned to the ABST for each of the tasks and make updates accordingly, especially accounting for escorts and monitoring when a COC is present. The community will also adjust staffing accordingly.
3. The ABST will be reviewed quarterly as assessments and service plans are updated.
4. The AL Administrator or their designee will monitor the ABST for accuracy and completion.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 4 of 4 direct care staff (#s 10, 11, 13 and 14) completed all required pre-service orientation and 3 of 4 hired staff (#s 11, 13 and 14) completed the required dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:
Staff training records were reviewed on 07/24/24 and revealed the following:
a. There was no documented evidence Staff 10 (MT) hired 07/05/23, Staff 11 (MT) hired 09/12/23, Staff 13 (CG) hired 08/14/23, and Staff 14 (CG) hired 08/29/23 had completed the following required pre-service orientation topics prior to beginning their job responsibilities:
* Resident rights and values of CBC care;
* Abuse reporting requirements; and
* Fire safety and emergency preparedness.
b. There was no documented evidence Staff 10, Staff 11 and Staff 13 were provided a written job description.
c. There was no documented evidence Staff 11, Staff 13 and Staff 14 had completed the following pre-service dementia care training topics prior to beginning their job responsibilities:
* Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics;
* Strategies for addressing social needs and engaging them in meaningful activities; and
* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach.
The need for staff to complete all required pre-service orientation and dementia training prior to starting their job responsibilties and providing care to residents was discussed with Staff 4 (Business Office Manager), Staff 1 (ED) and Witness 1 (Consultant) on 07/25/24. They acknowledged the findings.
The facility will take the following actions to correct C370:
1. All staff members identified in the ALF survey, 10, 11, 13, and 14, will complete pre-service training and any other identified training deficiencies by 9/23/2024.
2. Tanner Spring will review all policies and procedures for conducting and recording training and audit employee files to ensure that staff member training is complete and current.
3. Training records will be centrally located and audited semi-annually to communicate potential deficiencies well before due dates.
4. The Assisted Living Administrator or their designee will be responsible for completing and monitoring these actions.
There are no detail notes for this visit.
Based on interview, and record review, it was determined the facility failed to ensure 4 of 4 direct care staff (#s 10, 11, 13 and 14) had documented evidence of demonstrated competency in all required areas, and 2 of 4 direct care staff (#s 11 and 13) completed First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:
1a. Staff 10 (MT), hired 07/05/23, Staff 11 (MT) hired 09/12/23, Staff 13 (CG), hired 08/14/23, and Staff 14 (CG) 08/29/23 lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition;
* Conditions that require assessment, treatment, observation and reporting; and
* General food safety, serving and sanitation.
b. Staff 10 (MT) and Staff 11 (MT) lacked documented evidence of demonstrated satisfactory performance in the following required areas within 30 days of hire:
* Other duties as applicable (Med pass, treatments). In interviews on 07/24/24 and 07/25/24, Staff 10 and Staff 11 both described the training they had received and stated the trainer had documented their knowledge and competency. Staff 4 (Business Office Manager) acknowledged she could not locate the documentation.
2. Staff 11 and Staff 13 lacked documented evidence of having completed First Aid and abdominal thrust training within 30 days of hire.
The need to ensure hired direct-care staff completed training and demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 4 on 07/25/24 at 11:35 am and with Staff 1 (ED) and Witness 1 (Consultant) on 07/25/24 at 2:00 pm. They acknowledged the findings.
The facility will take the following actions to correct C372:
1. Staff members 10 and 11 will complete demonstrated competencies on med pass and treatments
Staff 11 and 13 will complete their First Aid and Abdominal Thrust courses by 9/23/2024.
2. Tanner Spring will review all policies and procedures for conducting and recording training and audit employee files to ensure that staff member training is complete and current.
3. Training records will be centrally located and audited semi-annually to communicate potential deficiencies well before due dates.
4. The Assisted Living Administrator or their designee will be responsible for completing and monitoring these actions.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure documented evidence 2 of 4 long-term staff (#s 7 and 15) completed a minimum of 12 hours of annual in-service training based on the staff person's anniversary date of hire, including at least six hours of dementia care. Findings include, but are not limited to:
Staff training records were reviewed on 07/24/24 and revealed the following:
a. There was no documented evidence Staff 15 (CG), hired on 04/20/22, completed a minimum of six hours of training on dementia care topics annually.
b. There was no documented evidence Staff 7 (CG), hired on 08/28/17, completed a minimum of 12 hours of training related to the provision of care in CBC, including a minimum of six hours of training on dementia care topics.
The need to ensure and document that long-term direct care staff completed the required number of hours of annual in-service training was discussed with Staff 4 (Business Office Manager), Staff 1 (Executive Director) and Witness 1 (Consultant) on 7/25/24. They acknowledged the findings.
The facility will take the following actions to correct C374:
1. Staff members 7 and 15 will be brought into training compliance by 9/23/2024.
2. Tanner Spring will review all policies and procedures for conducting and recording training and audit employee files to ensure that all staff member training is complete and current.
3. Training records will be centrally located and audited semi-annually to communicate potential deficiencies well before due dates.
4. The Assisted Living Administrator or their designee will be responsible for completing and monitoring these actions.
There are no detail notes for this visit.
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 failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:
On 07/25/24, fire and life safety records dated 03/2024 and 07/2024, were reviewed.
a. Fire drill records lacked documentation of the following required elements:
* Fire drill (conducted and recorded) on evening shift;
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed; and
* The number of occupants evacuated.
b. The facility provided no documented evidence staff were provided fire and life safety training on alternate months.
On 07/25/24 at 2:00 pm, the need to ensure fire drills were conducted according to the OFC and to provide fire and life safety instruction to staff on alternating months was discussed with Staff 1(ED) and Witness 1 (Consultant). They acknowledged the findings.
1. Actions taken to correct this rule violation are as follows:
a. The facility will implement an annual training plan that includes fire drills to be completed alternating months of fire and life safety training and includes:
* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time-period needed; and
* The number of occupants evacuated.
b. The facility will implement an annual training plan that includes fire and life safety training to be completed on alternating months of fire drills.
2. System will be corrected so that violation will not happen again by;
a. Comprehensive review of current fire drill forms to ensure they meet all required components.
b. In servicing provided to administration and or designee conducting fire and life safety drills and education on process and documentation required.
3. Area needing correction will be evaluated monthly by the Administrator and Maintenance Director.
4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures annually. Findings include, but are not limited to:
Review of facility fire and life safety records on 07/25/24 identified the following deficiencies:
* There was no documented evidence annual re-instruction on fire and life safety was provided to residents.
In an interview on 07/25/24 at 10:45 am Staff 5 (Maintenance Director) acknowledged the facility was not providing fire and life re-instruction to residents annually.
On 07/25/24 at 2:00 pm, the need to provide and document fire safety re-instruction to residents annually in accordance with the Oregon Fire Code was discussed with Staff 1 (ED) and Witness 1 (Consultant). They acknowledged the findings.
1. Action taken to correct this rule violation includes; a. All residents capable will be instructed 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 by 9/23/24. Annual re-instruction will be completed in the third quarter of every year thereafter. 2. Fire & Life Safety Training for Residents: This system is being corrected to eliminate future violations as follows: a. All new residents will be instructed of fire & life safety, within 24hrs of move-in, and reinstructed annually thereafter. b. All resident fire and life safety documentation will be filed and kept on-site, c. Facility Maintenance Director will keep an on-going spreadsheet of residents' admission dates, and dates of re-instruction d. Facility Maintenance director will bring all fire & life safety training for residents, to Quality Improvement Meetings for review. 3. This system will be evaluated as follows: a. Within 24hrs of a new resident admission, & b. Annually thereafter, c. Facility administrator will review fire & life safety for residents, at least once monthly to ensure compliance. 4. The Administrator, Maintenance Director and/or designee will be responsible to ensure corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure the relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C325.
Please see POC for C325
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses were maintained in good repair. Findings include, but are not limited to:
The exterior of the facility was toured on 07/23/24 through 07/25/24.
The exterior sidewalks in the courtyard had multiple drop-offs of up to three inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents.
The need to ensure all exterior pathways and accesses were maintained in good repair was discussed on 07/24/24 with Staff 1 (ED) and Staff 5 (Maintenance Director) and on 07/25/24 at 2:00 pm with Witness 1 (Consultant). They acknowledged the findings.
The facility will take the following action to correct C610:
1. The Maintenance Director will assess the area of concern and propose short-term and long-term solutions to the drop-offs in the courtyard.
a. In the short term, the community has filled the gaps with bark to level out where there is a drop-off.
2. The Administrator and the Maintenance Director will walk the area in the next 30 days to determine if the bark is solving the areas where a drop-off is occurring.
3. The Courtyard will be part of the monthly Safety Committee tour to determine if any additional hazards exist or if the bark needs to be refreshed in those areas.
4. The Administrator, Maintenance Director, or their designee will monitor for compliance.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant. Findings include, but are not limited to:
During observation of the facility on 07/23/24, the resident laundry room had washing machines in which residents' soiled clothing and linens were laundered. The washing machines had automatic laundry detergent dispensers. The laundry detergent used lacked a chemical disinfectant.
In an interview on 7/23/24 at 1:45 pm, Staff 7 (CG) stated she was unsure of the washing machine rinse cycle temperature or if the detergent used for resident soiled clothing and linens contained a disinfectant. She stated 80% of the residents were incontinent.
In an interview on 7/24/24 at 10:15 am, Staff 5 (Maintenance Director) stated the washing machine rinse temperature did not reach 140 degrees and the laundry detergent used at the facility contained a sanitizer and was unsure if it contained a disinfectant. Review of the chemical ingredients of the detergent did not include any chemicals listed as an approved disinfectant agent from the EPA List N.
The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 07/24/24 and Witness 1 (Consultant) on 07/25/24. They acknowledged the findings.
The facility will take the following actions to correct C630:
1. The Maintenance Director has replaced the automatic laundry detergent dispensers with a product that includes a chemical disinfectant.
2. The Maintenance Director will approve future detergent orders for these areas to ensure the appropriate detergent, which includes a chemical disinfectant, is installed.
3. The laundry rooms will be checked monthly for the appropriate chemicals, providing a regular and reliable system for maintaining compliance.
4. The Maintenance Director, Administrator, or their designee will monitor for compliance
There are no detail notes for this visit.
Concerns were identified and the facility was provided with technical assistance in the following areas:
The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (B) Engage in greater community life.
There are no detail notes for this visit.
Concerns were identified and the facility was provided with technical assistance in the following areas:
The setting is integrated in and supports the same degree of access to the greater community as people not receiving HCBS, including opportunities for individuals enrolled in or utilizing HCBS to: (D) Receive services in the greater community.
There are no detail notes for this visit.