The findings of the re-licensure survey, conducted 08/24/22 through 08/26/22, 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 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 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

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 08/26/22, conducted 12/20/22, 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 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 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

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 revisit, to the re- licensure survey of 08/26/22, conducted on 03/21/23, 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, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-0000. Findings include, but are not limited to:

Based on observations on 08/22/22 at 10:20 am, the facility kitchen needed cleaning and repair in the following areas:

a. Food spills, splatters, dirt, dust and black matter was observed on or beneath the following:

* Walls and light switch in dish washer area;

* Handwashing sink to the right of the ice machine;

* Inside microwave;

* Air conditioning unit vents above ice machine;

* The underside of the motor housing on the stand mixer;

* Telephone located on shelf at prep station;

* Floor around the deep fryer;

* Lower storage shelves of the steam table;

* Plate warmer;

* Handles and shelves of multiple serving carts;

* Large round floor fan; and

* Grates on the exhaust fans in the walk-in refrigerator.

b. The following areas needed repair:

* Caulking around the warewashing area;

* Weather strip on trim of the "In" door;

* Scoop holder next to the ice machine;

* Laminate was missing on the steam table cabinet;

* Paint was peeling from the "Out" door;

The areas needing cleaning and repair were reviewed with Staff 12 (Dietary Services Manager) on 08/22/22 and Staff 1 (ED) and Staff 8 (Plant Operations Assistant) on 8/24/22. They acknowledged the findings.

1. All identified areas in the kitchen have been deep cleaned, and all repairs have been completed or scheduled.

2. Routine cleaning schedules for kitchen and diet`ary carts have been updated to include areas that were missing. Dietary Manager will be reviewing cleaning schedules weekly, at a minimum, and will follow up as needed. Dietary Mananger will complete a monthly kitchen sanitation audit, to include repair work needed, and ensure any deficencies will be corrected timely.

3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly kitchen sanitation audits.

4. Executive Director and Dietary Manager will be responsible for maintaining this system

Based on interview and record review, it was determined that the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records from 01/2022 through 07/2022 were reviewed. The fire drill records did not consistently include documentation of the following required components:

* Location of simulated fire origin;

* Escape route used;

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

* Evacuation time-period needed; and

* Number of occupants evacuated.

In an interview on 08/25/22, Staff 7 (Plant Operations Manager) stated the facility was not relocating or evacuating residents as part of the fire drill process. While the facility had completed one full evacuation drill in April 2022, resident participation was not documented, and fire drill records revealed that residents were not consistently involved in the fire drill process.  

The need to ensure the facility conducted and documented fire drills according to the OFC was discussed with Staff 1 (ED) and Staff 7 on 08/25/22.  They acknowledged the findings.

1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills and all required components that must be documented. All staff were re-educated at staff meeting in September on the fire drill procedure.

2. To prevent recurrence, company fire drill form has been updated to include all required components and computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts.

3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

4. Executive Director, Arbor Administrator and Maintenance Director will be responsible for maintaining this system.

Based on record review and interview, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

On 08/25/22, Staff 1 (ED) was asked to explain the process of providing resident instruction upon admission and re-instruction annually.  Staff 1 (ED) stated that fire drill and safety procedures were not reviewed with the resident upon admission.  Staff 1 (ED) stated that reinstruction was not provided annually.

The need to ensure residents were instructed on general safety procedures within 24 hours of admission and re-instructed at least annually was discussed with Staff 1, Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/25/22.  They acknowledged the findings.

1. Fire and life safety training has been completed and documented for all current residents.

2. To prevent recurrence, admission packet has been updated to include a form to document fire and life safety training within 24 hours of admission. Environmental evaluation, which is completed semi-annually for all residents was also updated to include documentation of re-instruction on fire and life safety training. Programming has incorprated fire drills into qurterly activity's calendar.

3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance.

4. Executive Director, Arbor Administrator and Maintenance Director will be responsible for maintaining this system.

Based on interview and record review, 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 Z 155.

1. All Z tag violations will be resolved no later than 1/19/2023.

2. To prevent recurrence, refer to systems put in place for tag Z155.

3.All systems pertaining to tags will be evaluated as part of the monthly facitlity CQI program to ensure compliance.

4. Executive Director will be responsible for maintaining all systems.    

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

Observations of the facility on 08/24/22 revealed the following:

* The following areas were gouged or scraped, or needed to be painted:

- Trim missing on wall outside of dining room;

- Door of resident apartment 110 A;

- Ledge next to half door by Med-Tech desk;

- Trim in kitchen area; and

- Corners on right and left side of wall by 102 A.

* The following areas in the MCC kitchenette needed repair:

- Drawers; and

- Refrigerator door handle.

* Light fixtures throughout the dining room had visible debris in the fixture; and

* The upholstered benches located in the hallways had visible stains.

The facility was toured with Staff 1 (ED), Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant) on 08/25/22 at 1:00 pm. They acknowledged the findings.

1. All identified areas including doors, walls, light fixtures, machinery, and courtyard have been deep cleaned, and all repairs have been completed or scheduled.

2.  To prevent future occurrence, routine cleaning schedules for common areas have been updated to include areas that were missing.  A comprehensive walkthrough will be done once a week to be reviewed at standup meeting and a monthly groundskeeping audit has been implemented. Maintenance Director will also conduct monthly groundskeeping audit, monthly exterior inspections and monthly interior safety inspections to include repair work needed, and ensure any deficencies will be corrected timely.

3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly cleaning and repair audits.

4. Executive Director, Arbor Administrator and Maintenance Director will be responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to ensure compliance with non-healthcare related Residential Care and Assisted Living regulations. Findings include, but are not limited to:

Refer to C 240, C 420, C 422 and C 513.

1. All C tag violations will be resolved no later than 10/25/2022.

2. To prevent recurrence, refer to systems put in place for tags C240, C420c, C422 and C513.

3.All systems pertaining to C tags will be evaluated as part of the monthly facitlity CQI program to ensure compliance.

4. Executive Director will be responsible for maintaining all systems.

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation was completed and documented for 2 of 3 sampled newly hired direct care staff (#s 13 and 15) and 1 of 1 sampled newly hired non-direct care staff (#8); infectious disease prevention was completed for 1 of 2 sampled direct care staff (#14) and annual in-service training was completed for 1 of 3 sampled direct care staff (#14). Findings include, but are not limited to:

On 08/25/22 training records were reviewed with Staff 10 (Business Office Manager).  The following deficiencies were identified:  

a. Staff 13 (CG) was hired on 01/24/22 and Staff 15 (MT) was hired on 05/22/22 had not completed pre-service training in the following areas prior to providing care and services independently:

* 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.

b. Staff 8 (Plant Operations Assistant) was hired on 07/29/22. The following areas had not been completed before performing any job duties:

* Abuse reporting requirements;

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

* 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.

c. Staff 14 (CG) was hired on (05/14/19). There was no documented evidence Staff 14 completed the following training as required:

* Infectious disease prevention training was not completed by July 1, 2022; and

* A minimum of 16 hours of in-service training annually (based on anniversary date of hire) on topics related to the provision of care for persons in a CBC, including training on chronic diseases in the facility population with 6 of the 16 hours being dementia care topics.

The need to ensure that all newly hired staff completed pre-service and orientation prior to providing care and services independently, and veteran staff completed infectious disease prevention and annual in-service training was discussed with Staff 1 (ED) and Staff 10 on 08/26/22. They acknowledged the findings.  

1. A complete audit will be done of all training and competency records.  All trainings and competencies will be complete and up to date for current employees no later than 10/25/22.

2. To prevent recurrence, all staff will be required to complete the required training and job specific competencies within 30 days of hire.

Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components, to review the status of new hires' trainings to ensure all training is completed within 30 days of hire. Staff will not be allowed to work on the floor until pre-service training is complete.

3. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings.

4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem.     

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 sampled newly hired staff (#s 22 and 23) completed all required pre-service training, and 1 of 2 newly hired staff (#21) completed competency training within 30 days of hire or prior to independently providing personal care to residents. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 12/20/22. The following were identified:

a. Staff 22 (LPN) was hired 11/01/22. There was no documented evidence she had completed the following elements of the required pre-service orientation prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Standard precautions for infection control; and

* Fire safety and emergency procedures.

b. Staff 23 (CG) was hired 10/24/22. 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:

* 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.

c. Staff 21 (CG) was hired 09/02/22. There was no documented evidence she demonstrated competency in job duties within 30 days of hire and prior to working independently 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 facility's failure to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 1 (ED), Staff 5 (RCC) and Staff 10 (Business Office Manager) during interviews on 12/20/22. They acknowledged the findings.

1. A complete audit will be done of all training and competency records.  All trainings and competencies will be complete and up to date for current employees no later than 1/19/23.

2. To prevent recurrence, all staff will be required to complete the required training and job specific competencies within 30 days of hire.

Incomplete trainings and competencies will be reviewed five days a week as part of daily standup meeting to identify missing components, to review the status of new hires' trainings to ensure all training is completed within 30 days of hire. Staff will not be allowed to work on the floor until pre-service training is complete.

3. This system will be evaluated monthly as part of the facility CQI program and will include a review of all current staff members and the status of their required trainings.

4.  The Executive Director and Business Office Manager will be responsible for maintaining this sytem.

Based on observation, interview and record review, it was determined the facility failed to ensure outdoor furniture was of sufficient weight and design to prevent use in elopement, and the facility had an adequate policy for when the doors to the outdoor area could be locked. Findings include, but are not limited to:

a. On 08/24/22 at 2:30 pm, a tour of the courtyard revealed two chairs and one table that were light weight and could be moved by a resident to the fence to aid in elopement.

b. The policy provided by Staff 1 (ED) regarding resident access to the outdoor courtyard stated, "[MCCs] may secure the Arbor courtyard doors during specified hours determined by each community and during periods of inclement weather." Staff 1 stated the facility did not restrict resident access to the courtyard based on time of day but did restrict access based on extreme weather conditions. She acknowledged the current written policy did not clearly define these weather conditions for staff.

On 08/25/22 at 1:00 pm, the patio furniture and policy regarding resident access to the outdoor patio was discussed with Staff 1, Staff 7 (Plant Operations Manager) and Staff 8 (Plant Operations Assistant). They acknowledged the findings.

1. All furniture has been appropriately secured preventing a resident from moving furnitue to aid in elopment over the fence. Courtyard policy has been posted specifying to staff when to secure the courtyard.

2.  To prevent future occurrence, a comprehensive walkthrough will be done once a week to be reviewed at standup meeeting. Maintenance Director will also conduct monthly exterior inspections and monthly interior safety inspections to include environmental evaluations and ensure any deficencies will be corrected timely. To prevent recurrence, company Courtyard policy has been created to include circumstances to secure the courtyard.

3. System will be evaluated monthly as part of the Continuous Quality Improvement process to include a review of the monthly sanitation and repair audits.

4. Executive Director, Arbor Administrator and Maintenance Director will be responsible for maintaining this system.