The findings of the re-licensure survey, conducted 07/22/24 through 07/24/24, 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 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 re-visit to the re-licensure survey of 07/24/24, conducted on 10/11/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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 (#1) whose evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 11/2023 with diagnoses including end stage renal disease.

The Evaluation Screening Tool, dated 11/09/23, was reviewed and revealed missing information in the following required elements:  

* Customary routines regarding eating and bathing;

* Memory;

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

* How the resident expresses pain;

* Complex medication regimen; and

* Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, and room temperature.

The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (General Manager) and Staff 2 (Personal Care Director) on 07/24/24. They acknowledged the findings.

Our Evaluation Screening Tool has been corrected/revised to include all elements required by the regulations, at a minimum.

The Personal Care Director and Administrator will monitor for any future regulation changes to ensure this is updated accordingly.

Based on observation, interview, and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST) before a resident moved in, with amendments as appropriate within the first 30 days, whenever there was a significant change of condition, no less than quarterly, and failed to have an accurate number of minutes for 2 of 2 sampled residents (#s 1 and 2), and multiple unsampled residents whose ABSTs were reviewed. Findings include, but are not limited to:

a. Review of the facility's ABST revealed not all residents had been entered before a resident moved in, updated when there was a significant change of condition, or no less than quarterly for 12 out of 13 residents.

b. Resident 1 and 2's medical records were reviewed, observations were made of the residents, and staff were interviewed. The number of minutes assigned relating to the ABST were inaccurate.

The need to ensure the ABST was updated before a resident moved in, whenever there was a significant change of condition, no less than quarterly, and the resident's minutes were accurate for the staffing plan to meet the 24 hour scheduled and unscheduled needs of residents was discussed with Staff 1 (General Manager) and Staff 2 (Personal Care Director) on 07/23/24. They acknowledged the findings.

Upon survey assistance and training, staff have better understanding of the ABST and the regulation requirements. Facility was under the impression that it must be reviewed/updated only if there are changes.

Our Personal Care Director will utilize it each time there is a new move in, a significant change in condition, within 30 days of move in, and at least quarterly thereafter, updating it in tandem with the service plan and ensuring that it is reviewed even if there are no changes to the service plan.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term direct care staff (#s 5 and 6) completed 12 hours of annual in-service training which included dementia care training, and 1 of 2 long-term non-direct care staff (# 11) completed annual infectious disease training. Findings include, but are not limited to:

Staff training records for 2 direct care and 2 non-direct care staff were reviewed on 07/23/24.

a. Staff 5 (Personal Care Attendant), hired 04/07/16, and Staff 6 (Personal Care Attendant), hired 01/15/14, lacked documented evidence of the minimum required 12 hours of annual in-service training, which included six hours of dementia care training.  

b. Staff 11 (Dish Steward),  hired 06/15/21, lacked documented evidence she had completed the required annual infectious disease training.

The need to ensure that long term direct care staff completed 12 hours of annual in-service training which include six hours of dementia care training, and non-direct care staff completed the annual infectious disease training as required was discussed with Staff 1 (General Manager) on 07/23/24. She acknowledged the findings.

1) For Care Staff, we've updated our training records tracking forms to clearly show when training requirements are due. The Personal Care Director will also be assigning training throughout the year using Relias or Oregon Care Partners due each month. This will be monitored by the Personal Care Director and Administraor.

2) Annual Infectious Disease Training will be scheduled for the January all-staff meeting each year utilizing the Oregon Care Partners class (About Infection Control and Prevention). Any staff mamber unable to attend the training will be required to do it with a smaller group or individually within the same month. This error was based on the misunderstanding that the Pre-Service infection control training provided by OCP was sufficient. The facility overlooked that this was an annual training requirement. Employees who missed our recent training in January will undergo this training by September 22, 2024. This will be monitored by the Administrator and the Business Office Manager

Based on interview and record review, it was determined the facility failed to conduct and record unannounced fire drills every other month, and provide fire and life safety instruction to staff on alternating months, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were requested for the months of 01/2024 through 07/2024. Documentation was provided for the months of 03/2024 and 07/2024. Review of facility records on 07/23/24 identified the following:

* The facility failed to conduct and record unannounced fire drills every other month at different times of the day, evening, and night shifts; and

* The facility failed to document staff instruction on fire and life safety on alternating months.

The need to conduct and record unannounced fire drills every other month at different times, and document staff instruction on fire and life safety on alternating months in accordance with the OFC was discussed with Staff 1 (General Manager) and Staff 3 (Maintenance Director) on 07/23/24. They acknowledged the findings.

Our Safety Officer (Maintenance Director) has scheduled all our unannounced fire drills for the rest of the year and will continue to do so annually. This is scheduled on the Safety Officer's physical planner as well as through Outlook. This information is held confidential by the Safety Officer to ensure it is unanticipated by staff and residents. We have our drills scheduled monthly as opposed to every other month.

Every other month, our Safety Officer will be including fire and life safety training during our all-staff meeting.

This will be monitored by the Administrator and the Safety Officer

Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers for separate storage and handling of soiled linens and soiled clothing, a one-way flow of soiled laundry to preclude potential contamination, a flushing rim clinical sink with a handheld rinsing device, and the washers for soiled laundry had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:

A tour of the laundry facilities and interviews with staff on 07/23/24 revealed the following:

The laundry room was observed. There was no separate area with closed containers for separate storage and handling of soiled linens and soiled clothing, nor was there a one-way flow of soiled laundry to preclude potential contamination. Staff 9 (Housekeeper) was interviewed on 07/23/24. She confirmed she was responsible for the laundry process relating to the residents' linens and towels. Staff 9 did not know if the facility had a flushing rim clinical sink with a handheld rinsing device and she thought the laundry detergent included a disinfectant.   

Care staff were also interviewed on 07/23/24 regarding the laundry process, and they stated they rinsed soiled laundry in the resident's shower and they also thought the laundry detergent included a disinfectant.

During a tour of the laundry facilities on 07/23/24, Staff 1 (General Manager) and Staff 3 (Maintenance Director) confirmed the laundry detergent did not include a chemical disinfectant.

The need to ensure a safe and sanitary process for handling soiled laundry was discussed with Staff 1 and Staff 3 on 07/23/24. They acknowledged the findings. Staff 1 reported the facility ordered a detergent that was also a disinfectant at the end of the day on 07/23/24.

We have submitted a request for an exception to the ruling that we are required to have a flushing rim clinical sink with a handheld rinsing device. To add to the exception submitted to our policy analyst, it is noteworthy to mention that we have not had any outbreaks in our assisted living, or independent living section, despite the absence of such sink because of our already careful and thorough method of disinfection. Adding in the disinfectant additive noted below will also be an added measure moving forward.

In the realization that our laundry detergent did not have a disinfectant during survey visit, we contacted our chemicals provider, who has identified the proper disinfectant additive to the laundry. It is expected to arrive on 08/19/2024. We will be utilizing it on all soiled linens and soiled clothing moving forward.

This will be monitored by the Personal Care Director and Housekeeping Supervisor.