The findings of the re-licensure survey conducted 7/11/22 through 7/13/22 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 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

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 re-visit to the re-licensure survey of 07/13/22, conducted 06/15/23, are documented in this report. The survey was conducted to determine compliance with the 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

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 second re-visit to the re-licensure survey of 07/13/22, conducted on 08/28/23, 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.

Based on interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, and the condition was monitored to resolution at least weekly for 1 of 3 sampled residents (#2) who experienced changes of condition.  Findings include, but are not limited to:

Resident 2 was admitted to the facility in December 2021 with diagnoses including congestive heart failure and diabetes.

The resident's 06/21/22 service plan, 04/12/22 through 07/11/22 progress notes, temporary service plans and physician communications were reviewed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Injury and non-injury falls;

* Hospitalization, skilled nursing return and ER trips;

* Behaviors, both verbal and physical aggression;

* Smoking;

* Fractures and cast removal;

* Chest pain and blood in brief; and

* New medications and medication changes.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Executive Director), Staff 2 (Director of Health Services/RN) and Staff 6 (LPN) on 07/12/22. The staff acknowledged the findings.

1. Resident #2 Service plan has been updated to reflect resident specific directions to staff regarding behaviors, smoking, history of falls with & without injuries, hospital & ER visits.  Reviewed with the Nurses in charge of clearing alerts after specific time, explaining each indivdual alert needs to be addressed and closed sepratley, avoiding the intentions to close multiple alerts on Resident #2 in one documentation.  

2. To prevent reoccurance, staff will be reeducated on the alert charting guidelines and when to notify the RN.  ED & RN will review all residents on alert and have a discussion ensuring short term change of conditions are being implemented and communicated, and alert charting process is complete.  RN will ensure the Daily Alert Charting Audit Form is up to date, a form where residents are put on when they are being monitored.

3. The system will be evaluated five days a week as part of the daily stand up meeting.  this system will further be evaluated monthly, as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring.  

4. RN, RCC & ED will be responsible to ensure current & new hired staff receive appropriate training in understands reporting of Change in Condition.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired direct care staff (#s 11, 12 and 13) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were requested on 07/12/22 from Staff 1 (Executive Director) who stated the facility was behind in documenting competencies for caregivers.

There was no documented evidence Staff 11 (CG), Staff 12 (MT), or Staff 13 (CG), hired 05/29/22, 05/06/22, and 05/16/22, respectively, demonstrated competency in all assigned job duties within 30 days of hire in the following areas:

* Providing assistance with ADLS;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition; and

* Conditions that require assessment, treatment, observation, and reporting.

The need to ensure newly-hired direct care staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 on 07/13/22. No further documentation was provided.

1. Reviewed Staff 11, 12, 13's new hire paperwork and learned their compentency checklist had not been signed as required by trainee/trainer and follow up was not completed by supervisor. This prompting an audit for all current staffing, & implementing a staffing tool with required items on list & use as a guide.  All competenties have been reviewed and signed.

Reviewed pre-service required training in the LMS.  Printed transcripts (instead of certificates)  and placed in staff binder to have on hand and ensure required training is completed.  Required 6 hours of Dementia training was noted on the transcripts as Alzheimer's Disease & related Disorders, completed as well  for new hires 11,12,13 along with "Your Body at 80" also addresses Changes associated with Normal Aging also noted.

2 and 3. RCC will be updating a staffing ladder with required information to use as a guide and follow through with ensuring each new hire is checked for competency of their job within their first 30 days of employment.  ED will be checking on the progress once a month, provide guidance as needed. Office Manager will monitor LMS system for required pre-service and orientation compliance.  Additionally, the system will be evaluated as part of the facility continuous quality improvement process, including a review of all new hires and ongoing annual trainings each month.

4. Executive Director and Office Manager will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 long-term staff (#s 7, 14, and 15) completed the required minimum 12 hours of in-service training annually. Findings include, but are not limited to:

Annual staff training, including monthly staff meetings and online training, were reviewed on 07/12/22.

There was no documented evidence Staff 7 (CG), hired 11/28/05, Staff 14 (CG), hired 01/17/14, and Staff 15 (CG), hired 10/05/15, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1 (Executive Director) on 07/13/22. She acknowledged the findings.

1. ED/DHS/RCC have reviewed staff training records and have started scheduling staff to complete their monthly training in person and in the LMS, in order to remain in compliance with required 12 hours (6 being dementia) training.

2. Executive Director will review and update Relias training to ensure it is matching to the OARs training requirements.  In addition, ED review with RCC Pre-Service and Annual training requirements.  Executive Director and Human Resources will be responsible to ensure staff completes the required annual training.  The staffing ladder/training grid will be maintained to keep track of the progress of staff training.  

3. Once a month ED will be reviewing this tool and making sure it is up to date.  Additionally, the system will be evaluated as part of the facility continuous quality improvement process, including a review of all new hires and ongoing annual trainings each month.

4. Executive Director, RCC and Office Manager (HR) will be responsible for ongoing compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drill records included documentation of all required elements and fire and life safety instruction to staff was provided on alternate months from fire drills. Findings include, but are not limited to:

Fire and life safety records, including staff meetings, were reviewed from January 2022 through June 2022. The following deficiencies were identified:

a. Fire drill records did not include the following required elements:

* Escape route used;

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

* Number of occupants evacuated.

b. There was no documented evidence of fire and life safety instruction consistently provided to staff on alternate months.

In an interview on 07/13/22, Staff 9 (Maintenance Director) acknowledged the facility was not relocating residents as part of the fire drill process. In addition, he reported that fire and life safety training was provided during staff meetings but had been suspended due to the pandemic.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 9 on 07/13/22 at 8:45 am with Staff 1 (Executive Director) on 07/13/22 at 11:15 am. They acknowledged the findings.

1. A traini was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills.  all staff will be reeducated at the next staff meeting on the fire drill procedure.

2. To prevent reoccurance, the company fire drill form will be utilized and filled out completely, including all required components.  Staff will be educated on fire and life safety at every other all staff meeting and a fire drill will be conducted per regulation, two times a year on each shift.  ED and Maintenance Director will meet monthly to review fire drills and education, to ensure ongoing compliance.   

3. ED will work closely with Maitenance Director & schedule in advance fire drills and inservices with staff on alternate months to maintain consistency.  Fire drills and fire and life safety trainings will be reviewed monthly as part of the CQI process to ensure compliance.

4. ED/Maintenance Director will be responsible to maintain the system and ensure the documentation is complete with each inservice and fire drill.   

Based on interview and record review, it was determined the facility failed to re-instruct residents, at least annually, in 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. Findings include, but are not limited to:

In an interview on 07/13/22, Staff 1 (Executive Director) stated the facility did not have a process for providing instruction to residents at least annually in the required elements of fire and life safety procedures.

The need to ensure residents were provided fire and life safety instruction at least annually per the Oregon Fire Code was discussed with Staff 1 on 07/13/22. She acknowledged the findings.

1. Fire and life safety training will be completed and doucmented for all current residents.

2. To ensure residents are educated and informed of Fire Safety and Evacuations we will review with each resident at move in, at 30-days and quarterly.  This will be noted on the Care Conference Review.

3. Will review Fire & Life Safety at Resident Counsel that is held by the residents each month.  What is reviewed and Discussed will be noted on the meeting minutes.  This process will be reviewed monthly as part of the CQI process to ensure compliance.

4. ED/Maintenance Director/RCC will be responsible to maintain this system quarterly and update information as needed.

Based on observation and interview, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C 613.

C455

New plan of correction has been established to adequately improve in areas of ciatation C613 (see below).  ED, LPN Supervisor and Plant Operations Manager will be doing  walk-throughs to ensure areas of concern are addressed.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:

Observations of the facility on 07/11/22 and 07/12/22 showed the following areas in need of cleaning or repair:

* Multiple walls on all three floors had scrapes, chipped paint, drips or gouges;

* Chairs in the first floor living room and near the nurse's office had white and brown spills/splatters. A striped chair in the main sitting area had a long cut to the side of the fabric and two side tables had multiple chips and exposed wood;

* Handrails outside both elevators on the second and third floor and near Room 222 had long scrapes with missing paint and sections of black/purple discoloration;

* Scrapes, dings and long black streaks were noted on doors and/or door frames at Rooms 105, 205, 206, 207, 208, 213, 215, 224, 309 and 317;

* The second and third floor laundry rooms had debris and dead insects in the light fixtures, scraped/chipped paint to the walls and windowsill and chipped counter tops with missing pieces of laminate;

* The third floor laundry room had multiple long gaps in the floor with seams pulling apart and missing chunks of flooring in several sections at seams and around the drain;

* The small elevator walls were scraped, gouged and/or chipped. Doors and door frames outside both elevators had large gouges with missing pieces of wood; and

* The commercial laundry room was noted to have multiple large scrapes across doors and walls, laminate was pulling away from the small sink and the caulking around the hopper sink was missing with gaps between the flooring and sink. Multiple pieces of linoleum were missing, flooring was cracked and seams were pulling apart. Debris and dust was noted behind the washing machines.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 (Executive Director) on 07/12/22. She acknowledged the findings.

1. Reviewed the findings with Maintenance Director & Director of Housekeeping, each have neen assigned to work on repairs of the interior of the building: resident's doors, handrails, cleaning the light fixtures, repairing & painting of the walls & door frames, repairing or replacing flooring in laundry rooms, counter tops, and other areas that were identified.  Information in photos have been shared with both teams, and they are in the process of addressing and scheduling repairs and setting cleaning routines.

2. Executive Director will touch base with each team once a week to ensure routine cleaning and non-cleanable surfaces are in good repair or in process of being repaired as needed.

3. Cleaning and repair needs will be reviewed 5 days a week at daily stand up meeting and monthly as port of our CQI process to ensure compliance. Executive Director, Maitenance Director & Housekeeping Director will conduct an interior monthly walk-through to ensure the building is clean and in good repair.

4. ED, Housekeeping Supervisor and Maintenance Director will be responsible for maintaining this system.   

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces and all equipment necessary for the health, safety, and comfort of the residents was kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

Observations of the facility on 06/15/23 revealed the following:

* Gouged and scraped doors and/or jambs were observed in the following areas:

- Resident rooms 101, 103, 203, 206, 207, 215, 222, 225, 227, 233, 235, 236, 309, 315 and 344;

- Entrance door to kitchen;

- Men's first floor bathroom; and

-  Elevators on all three floors.

* The wall underneath the fireplace in the first-floor television room had gouges and scrapes in the paint and drywall;

* A wall in the dining room (next to the kitchen door) had a long scrape above the chair rail;

* A second-floor sink/cabinet located in the hallway near Room 211 had food matter and spills in the sink basin and on the counter top;

* The third-floor laundry room folding counter was missing an approximate 2X8 inch strip of laminate from the edge; and

* A striped chair in the first-floor television room had an approximate five-inch rip in the fabric on the right side.

The surveyor toured the environment with Staff 17 (Executive Director) on 06/15/23 at 11:45 am. She acknowledged the findings.

C613

1. Gouged and scraped doors and door jambs will be repaired by maintenance before 7/30/23.  The Executive Director will walk through all 3 floors of facility with Plant Operations Manager on a weekly basis x 4 weeks to ensure that all areas are repaired and maintained.  After 4 weeks, walk throughs will continue at least once monthly to review areas that need repairs.  

2. Maintenance staff will increase to repairing walls, door frames, doors to at least once monthly to keep them well maintained

3. Second floor sink area has been cleaned with bleach and trash under sink has been taken out.  Caregivers on the night shift will have added responsibilities to clean the sink area on each floor and take out the trash.  Executive Director or LPN Supervisor will round at least 3 x weekly for 4 weeks to ensure that area is clean and tidy.  After 4 weeks, managers will round at least weekly to ensure that it continues to be maintained.

4. The counter in the 3rd floor laundry room has missing laminate on the edge.  This counter will be removed and replaced with a new counter.  Executive Director weekly rounds with Plant Operations Manager will include checking laundry area to ensure that the area is maintained x 4 weeks, then monthly rounds thereafter.

5. The striped chairs in the first floor television room have been removed and replaced with alternate chairs with no tears.  Executive Director weekly rounds with Plant Operations Manager will include assessing furniture to ensure it is in good repair x 4 weeks, then monthly rounds thereafter.