The findings of the re-licensure survey, conducted 09/06/22 through 09/07/22, 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 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
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 revisit to the re-licensure survey of 09/07/22, conducted on 01/03/23, 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.
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 09/07/22, conducted on 05/12/23, 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.
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 third revisit to the re-licensure survey of 09/07/2022, conducted on 09/19/2023 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.
Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a conspicuous location for residents, visitors and available for inspection at all times. Findings include, but are not limited to:
During a tour of the environment on 09/06/22, there were no postings related to the administrator or designee in charge, the current facility staffing plan or a copy of the most recent survey in an accessible or conspicuous location.
The findings were reviewed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
152 OAR 411- 054- 0025 (5) Facility Administration: Required Postings
1. Immediate actions taken to correct the rule violations include posting the following:
a) Administrator or Designee in charge
b) Current facility staffing plan
c) Copy of the most recent survey in a conspicuous location.
2. The system will be corrected so this violation will not happen again by adding these items to the survey readiness binder to ensure consistent auditing and replacement of any missing postings timely.
3. This area needing correction will be evaluated monthly.
4. The Administrator or Designee will be responsible to see that the 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 move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 10/2021 with diagnoses including seizure disorder.
The resident's move-in evaluation failed to address the following required elements:
* Customary routines related to eating and bathing;
* Personality including how the persons copes with change or challenging situations;
* Recent losses;
* Unsuccessful prior placements; and
* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, and room temperature.
The need to address all required elements of the move-in evaluation was discussed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
C 252 SS=D OAR 411-054-0034(2)(3)(4) Resident Move-in and Eval: Res Evaluation
1. Immediate actions taken to correct this rule violation include updating Resident #2's evaluation to reflect the following required elements: Customary routines related to eating and bathing; Personality including how the persons copes with change or challenging situations; recent losses; unsuccessful prior placements, and environmental factors that impact the residents behavior including but not limited to noise, lighting, and room temperature.
2. To ensure the system will be corrected so this violation will not happen again, evaluations including all required factors will be completed per Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. 100% of current Resident evaluations will be reviewed and updated to reflect all required components.
3. The area will need to be reviewed and audited prior to any new Resident move in, and the system will be reviewed to ensure compliance with OAR's on a quarterly basis.
4. Administrator, RN or designee will be responsible to ensure the corrections are completed and Monitored.
Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 5) whose new move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 11/2022 with diagnoses including history of alcohol dependence.
The resident's move-in evaluation failed to address the following required elements:
* Personality including how the persons copes with change or challenging situations; and
* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting and room temperature.
The need to address all required elements of the move-in evaluation was discussed with Staff 1 (Administrator) on 01/03/23. He acknowledged the findings.
C 252 SS=D OAR 411-054-0034(1-6)) Resident Move-in and Eval: Res Evaluation
1. Immediate actions taken to correct this rule violation include updating Resident #5's evaluation to reflect the following required elements: Personality, including how Resident #5 copes with change or challenging situations; and environmental factors that impact the residents behavior including but not limited to noise, lighting, and room temperature.
2. To ensure the system will be corrected so this violation will not happen again, evaluations including all required factors will be completed per Oregon State Rule prior to move in, updated within 30 days, quarterly thereafter and with any significant change of condition. 100% of current Resident evaluations will be reviewed and updated to reflect all required components.
3. The area will need to be reviewed and audited by the RN or Trained Designee prior to any new Resident move in, and the system will be reviewed to ensure compliance with OAR's on a weekly basis.
4. Administrator, RN or designee will be responsible to ensure the corrections are completed and Monitored.
There are no detail notes for this visit.
Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of current care needs and provided clear direction to staff for 1 of 3 sampled resident (# 2) whose service plan was reviewed. Findings include, but are not limited to:
Resident 2 was admitted to the facility in 10/2021 with diagnoses including seizure disorder.
The resident's service plan did not reflect his/her current care needs and lacked specific instruction to staff in the following areas:
* Interventions for seizure activity;
* Recent falls including fall risk interventions; and
* Dental status including denture care.
The need to ensure Resident 2's service plan was reflective of his/her needs and included clear direction to staff was discussed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
C 260 SS=E OAR 411-054-0036(1-4) Service Plan: General
1. Immediate actions taken to correct the rule violatio include updating Resident #2's service plan to reflect specific instruction to the staff in the following areas:
a) Interventions for seizure activity
b) Recent falls including fall risk interventions
c) Dental status including dental care
2. The system will be corrected so this violation does not happen again by ensuring that the service plan is created to reflect the Residents current status prior to Move in, within 30 days, every 90 days therafter or with any significant change of condition per company policy and Oregon State Rule. All Resident Service plans will be reviewed and updated to reflect any changes or personalization via "Temporary service plan". All updates to the service plan are placed in the 24 hr book for all staff to review and sign off on.
3. The area needing correction will be evaluated Quarterly and with significant changes of condition.
4. Nursing or designee will be responsible to see that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to ensure initial service plans were completed and accessible to staff for 1 of 2 sampled residents (# 5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:
Resident 5 was admitted to the facility in 11/2022 with diagnoses including history of alcohol dependence and hypertension.
The resident's initial service plan was not completed and accessible to staff.
The need to ensure Resident 5's service plan was completed upon move-in and was accessible to staff was discussed with Staff 1 (Administrator) on 01/03/23. He acknowledged the findings.
C 260 SS=D OAR 411-054-0036(1-4) Service Plan: General
1. Immediate actions taken to correct the rule violation include updating Resident #5's service plan to reflect all required components per OAR's and is easily accessible to all staff for review at any time.
2. The system will be corrected so this violation does not happen again by ensuring that the service plan is created to reflect the Residents current known status prior to Move in, within 30 days, every 90 days therafter and/or with any significant change of condition per Oregon State Rule. All Resident Service plans will be reviewed and updated to reflect any changes or personalization via "Temporary service plan". All updates to the service plan are placed in the 24 hr book for all staff to review and sign off on. For all service plan reviews, once all staff have signed, the Service plan will be placed in the Service plan binder. This will hold the most recent service plan for each Resident, and signed TSP's that reflect active changes or updates will be placed on top of the service plan. SP binder will be located on the shelf just outside the Clinical/ Admin office to ensure all Staff have access for review.
3. The area needing correction will be evaluated Weekly and with significant changes of condition. The RN should review and update service plans with directions for staff to follow and what to report related to nursing needs such as diabetic monitoring or management, complex wound care, significant weight loss or gain interventions, care for Residents on hospice, or those with multiple falls, for example.
4. The Administrator, Nurse or designee will be responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview and record review, it was determined the Administrator failed to show documented evidence of a Residential Care Facility Administrator license. Findings include, but are not limited to:
On 09/06/22, Staff 1 (Administrator) was asked to provide documentation of his Residential Care Facility Administrator license. Staff 1 revealed he had not obtained his license.
The requirement to have a current Residential Care Facility Administrator license was discussed with Staff 1 on 09/07/22. He acknowledged the findings.
C 355 OAR 411-054-0065 (2-6) Administrator: Administrator Requirements
1. Immediate actions taken to correct the rule violation include: Finger print- Done, High School diploma- just received in mail
2. The system will be corrected so this violation will not happen again by John Varner to fill application ASAP
3. This area needing correction will be evaluated on a
Yearly Basis
4. The Administrator will be responsible to see that the corrections are completed and monitored.
There are no detail notes for this visit.
Based on interview, it was determined the facility failed to implement an Acuity-Based Staff Tool (ABST) by July 1, 2022 to determine appropriate staffing levels for the facility. Findings include, but are not limited to:
On 09/06/22, Staff 1 (Administrator) was asked to provide evidence the facility had implemented an ABST to determine appropriate staffing levels for the facility. Staff 1 stated the facility had not implemented an ABST.
The need to ensure the facility implemented an ABST was reviewed with Staff 1 on 09/07/22. He acknowledged the findings.
C 361 OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool
1. Immediate actions taken to correct the rule violation include immediately adopting the ABST (acuity based staffing tool) to determine appropriate staffing levels for the community. Donham Place chooses to adopt the Departments ABST tool to ensure compliance with the rule.
2. To ensure the system is corrected so the violation will not happen again, Donham Place will ensure the ABST assessment is completed for each Resident before move in, within 30 days, quarterly and whenever any Resident has a significant change of condition.
3. This area needing corrected will be evaluated on a quarterly basis.
4. The Administrator, RN or Designee will be responsible to see that the corrections are completed and monitored.
Based on interview and record review, it was determined the facility failed to complete an Acuity-Based Staffing Tool (ABST) assessment for each resident and update the ABST quarterly. This is a repeat citation. Findings include, but are not limited to:
In an interview on 01/03/22, Staff 1 (Administrator) confirmed the facility had not entered all residents into the their ABST tool and he was not aware the ABST required updating at least quarterly.
1. Resident 5 was admitted to the facility in 11/2022. Resident 5's care needs were not entered into the ABST.
2. Resident 4's quarterly service plan was completed in 12/2022; however, the ABST was last updated in 10/2022.
The need to complete an ABST assessment for each resident and updated the ABST quarterly was reviewed with Staff 1 on 01/03/23. He acknowledged the findings.
C 361 OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool
1. Immediate actions taken to correct the rule violation include adding Resident #5's care needs into the ABST (acuity based staffing tool). Donham Place continues to choose to adopt the Departments ABST tool to ensure compliance with the rule.
2. To ensure the system is corrected so the violation will not happen again, Donham Place will ensure the ABST assessment is completed for each Resident along with their prior to move in, within 30 days, quarterly and significant change of condition evaluation/ SP update. Updates to the ABST will reflect the areas identified within the most recent evaluations to determine appropriate staffing levels for the community in real time, in response to Residents' changing needs.
3. This area needing corrected will be evaluated on a monthly basis to ensure the ABST is reflective of the changing needs of current and new Residents.
4. The Administrator, RN or Designee will be responsible to see that the 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 pre-service dementia care training had been completed, with certification, prior to staff providing direct care to residents, for 1 of 1 newly hired staff (#5). Findings include, but are not limited to:
The facility's training records reviewed on 09/07/22 revealed:
Staff 5 (CG), hired 06/27/22, lacked documented evidence they had completed the required pre-service dementia training prior to providing direct care to residents.
Requirements for pre-service dementia care training were reviewed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
C 370 OAR 411-054-0070 (3-4) Staffing Rqmts and Training: Caregiver Rqmts
1. Staff member #5 completed pre-services course on 9/10/22
2. The system will be corrected so this violation will not happen again by ensuring that all new hires will undergo the required pre-service dementia training prior to providing direct care to residents.
3. The area needing corrected will be evaluated on a quarterly basis.
4. The Administrator or Designee will be responsible to see that the 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 documented evidence of the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 1 of 2 veteran staff (# 3) whose training records were reviewed. Findings include, but are not limited to:
Staff training records were reviewed with Staff 1 (Administrator) on 09/07/22.
Staff 3 (Universal Worker) was hired 05/2004. Annual training records, provided through online training courses and monthly staff meetings, between 05/2021 and 05/2022 were reviewed.
The records indicated Staff 3 did not complete all six hours of in-service training on topics related to dementia care.
The need to ensure direct care staff completed the required annual training was reviewed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
C 374 OAR 411-054-0070 (5-7) Annual Training and Other Requirements
1. To immediately correct this rule violation, Staff #3 will complete all 6 hours of in-service training on topics related to dementia care.
2. The system will be corrected so this violation will not happen again by ensuring documented evidence of the required 12 hours of annual in- service training, including 6 hours of dementia care training is completed for all staff.
3. This area needing correction will be evaluated on a quarterly basis to ensure ongoing compliance.
4. The Administrator or Designee will be responsible to see that the 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 their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 252, C 260, C 361 and C 513.
C 455 SS=F OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval
1. Immediate actions taken to correct the rule violation include
2. To ensure the system is corrected so the violation will not happen again, Donham Place will self audit, correct and ensure all rule violations are in compliance prior to the next re-licensure survey.
Refer to C 252, C 260, C 361 and C 513
3. This area needing corrected will be evaluated on a monthly basis to ensure all open citations are moved into and remain in compliance with OARs.
4. The Administrator, RN or Designee will be responsible to see that the corrections are completed and monitored.
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. This is a repeat citation. Findings include, but are not limited to:
Refer to C 513.
See- C 513
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to keep all interior materials, surfaces and all equipment necessary for the health, safety and comfort of the residents clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
The interior of the building was toured on 01/03/23 at 12:48 pm. The following areas needed cleaning or repair:
* The threshold at room six was missing which created an uneven surface and potential tripping hazard;
* The threshold between the entrance and the stairs was missing;
* Wood door frame into the television room had scrapes, gouges and paint missing;
* The ceiling in the first floor bathroom and the TV room were stained brown;
* The threshold of the first floor bathroom was missing;
* The shower curtain in first floor bathroom had black spotting;
* Light switches in both bathrooms were broken;
* The light switch in the upstairs bathroom had brown staining;
* The threshold near kitchen was missing;
* Three balusters were missing in the stairway railing;
* The staircase railing had chipped paint;
* Door frame at top of stairs had paint chipping and an exposed sharp surface;
* Floorboard outside second floor bathroom was broken with subflooring exposed; and
* Multiple doors on the second floor had brown staining, gouges and paint missing.
On 01/03/23 at 1:50 pm, the building's interior was toured with Staff 1 (Administrator). He acknowledged the findings.
C 513 SS=F OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors
1. Immediate actions taken to correct the rule violation include repairs and cleaning all areas identified as out of compliance during the previous re-visit survey. The areas left to resolve/ address include: Repair gouged paint, Staining/ repainting, repair floors, Light Switches, Missing Stair spindals. These outstanding areas found out of compliance will be addressed and resolved by 3/20/2023.
2. To ensure the system is corrected so the violation will not happen again, Donham Place will initiate a maintinence request binder Staff, Residents and/ or Visitors can inform of areas that should/ could be addressed to ensure the health, safety, and comfort of the Residents, and that their environment remains clean and in good repair. The Administrator or Designee will sign off once the area has been addressed and issue resolved.
3. This area needing corrected will be evaluated on a quarterly basis with an environmental audit (or during the safety meeting, for example).
4. The Administrator Designee will be responsible to see that the corrections are completed and monitored.
Based on observation and interview, it was determined the facility failed to keep all interior materials, surfaces and all equipment necessary for the health, safety and comfort of the residents clean and in good repair. This is a repeat citation. Findings include, but are not limited to:
The interior of the building was toured on 05/12/23 from 10:00 am to 10:30 am. The following areas needed cleaning or repair:
* The floor threshold at room six was missing which created an uneven surface and potential tripping hazard;
* Entryway wall of upstairs TV room, near Room 5, was missing sheetrock and framing;
* Upstairs TV room floor, near Room 5, was missing floor covering which created a potential tripping hazard and uncleanable surface;
* Door frame into the kitchen was missing;
* Door frame out of the kitchen had scrapes and gouges;
* Door frame, into the medication room, had scrapes and gouges;
* Ceiling light fixtures near janitor storage area and near dining room were broken and had exposed wires;
* There were gaps in the ceiling where the ceiling and wall join, near the janitor area;
* The janitor storage and drain area were cement which created an uncleanable surface; and
* Multiple holes in the wall, around fire alarm control panel.
On 05/12/23 at 1:40 pm, the building's interior was toured with Staff 1 (Administrator). He acknowledged the findings.
1) We have a handyman coming june 18th to help with these repairs. The stainless steel end caps for the door jams should arrive by july 10th
2) We are putting together a repair log to stay on top of needed repair items.
3) I have asked the staff to help with anything they see that might need fixing and bring it to my attention and to write it in the log.
4) The Admin.
There are no detail notes for this visit.
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 09/06/22 revealed the following areas were in need of cleaning or repair:
* Scrapes, gouges and paint missing on wood door frame into the television room;
* Holes on the wall in the stairway;
* The chairs on the second floor sitting area were missing fabric and were not a cleanable surfaces;
* Resident Apartment One had a hole in the wall; and
* The window sills upstairs had a build-up of black dirt and debris.
The areas in need of cleaning and repair were discussed with Staff 1 (Administrator) on 09/07/22. He acknowledged the findings.
C 613 OAR 41-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable
1. Immediate actions taken to correct the rule violation include cleaning and or repairing the following:
a) Scrapes, gouges and missing pain on wood door frame into the TV room has been repaired.
b) Holes on the wall in the stairway will be repaired
c) The chairs on the 2nd floor sitting area will either be replaced, or the missing fabric will be repaired to ensure they are cleanable surfaces.
d) Hole in the wall in Apt #1 will be repaired
e) Window sills upstairs will be cleaned and will be free of debris and black dirt.
2. The system will be corrected so this violation will not happen again by re-educating staff at next all staff meeting to notify the Administrator of any enviornmental concerns as they come up via the Maintenance log. The environmental issues will then be followed up on and resolved timely.
3. This area needing correction will need to be evaluated on a monthly basis.
4. The Administrator or Designee will be responsible to see that the corrections are completed and montiored.