The findings of the relicensure survey conducted 02/28/23 through 03/01/23 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 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 revisit to the re-licensure survey of 03/01/23, conducted 06/26/23, 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.

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 revisit to the re-licensure survey of 03/01/23, conducted 08/24/23 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.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to the care of the dementia resident, was completed for 2 of 2 long-term staff (#s 3 and 14) whose training records were reviewed. Findings include, but are not limited to:

Staff 9 (RCC) was hired 01/2015 and Staff 10 (MT) was hired 04/2014.

a. Staff 9 failed to have documented evidence of completing 12 hours of annual in-service training including six hours of annual in-service training related to the care of the dementia resident, between 01/2022 and 01/2023.

b. Staff 10 failed to have documented evidence of completing 12 hours of annual in-service training including six hours of annual in-service training related to the care of the dementia resident, between 04/2021 and 04/2022.

The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Executive Director), Staff 4 (Resident Services Director) and Staff 12 (Business Office Manager) during the survey. They acknowledged the findings. No further information was provided.

C 374 OAR 411-054-0070 (5-7) Annual Training and Other Requirements

Findings showed that direct care Staff 9 and Staff 10 did not have documented evidence of the required 12 hours of annual in-service training including six hours of training related to dementia.The facility will provide the necessary training for these employees to ensure compliance.

The facility will ensure that all direct care staff complete a minimum of 12 hours of in-service training annually on topics related to resident care. The facility will also ensure all direct care staff have six hours of dementia training by the anniversary of their hire date and annually thereafter. This training will be documented and kept in the employee file.

The Executive Director and Office Manager, will review compliance monthly and will monitor the correction of this deficiency and ensure compliance going forward.

Based on interview and record review, it was determined the facility failed to have documented evidence that 12 hours of annual in-service training, including six hours related to dementia care, was completed for 1 of 1 long-term direct care staff (#14) whose training records were reviewed and the facility failed to ensure the training program was approved by the Department. This is a repeat citation. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 1 (Executive Director) on 06/26/23 at 2:30 pm. The following was identified:

* Staff 14 (MT), hired on 04/29/2022, failed to have documented evidence 6 hours of dementia care was completed; and

* The facility was using a training curriculum (Healthcare Academy) that was not approved by the Department.

The need to ensure long term direct care staff completed 12 hours of annual in service that included 6 hours of dementia care topics that was approved by the Department was discussed with Staff 1 on 06/26/23. She acknowledged the findings.

C 374 OAR 411-054-0070 Annual Training and Other Requirements

411-054-0005(19)

Staff 14 was identified as not having documented evidence of 6 hours dementia care training completed as part of the 12 hour annual inservice training and failed to ensure the training program was approved by the Department.

Facility understands that Health Care Academy is not an approved training program, and does not meet the curriculum requirements by the State of Oregon. Going forward, all required training will be done only through Oregon State approved programs.

All employee files will be audited to ensure they have completed the required 12 hour annual inservice training including 6 hours related to dementia care.

Going forward, the facility will use a training checklist to monitor training for all employees.

The Executive Director and Assistant Executive Director/Office Manager will be responsible to see that these corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to staff on alternating months. Findings include, but are not limited to:

On 02/28/23, fire drill and fire/life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* No fire and life safety instruction was provided to staff.

On 03/01/23 at 9:00 am, Staff 1 (Executive Director) informed the survey team that fire and life safety instruction had not been provided to staff per the rule. The requirements regarding fire and life safety instruction were reviewed with Staff 1. She acknowledged the findings.

420 OAR 411-054-0090 (1-2) Fire and Life Safety

The facility will ensure that Fire and Life Safety instruction is provided to staff on alternate months ongoing.

The facility held an all-staff meeting on 3/14/23 that covered fire and life safety, including fire drill procedures, evacuation procedures, R.A.C.E, and P.A.S.S. This training was documented.

The Executive Director and Maintenance Director will monitor the correction of this deficiency and will ensure going forward that all new team members and current team members receive fire and life safety instruction per the rule. All training will be documented.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of admission and annually. Findings include, but are not limited to:

Fire and life safety records were requested during the survey. The following deficiencies were identified:

* Documentation of fire and life safety training provided to residents within 24 hours of move in; and

* Documentation of annual fire and life safety training provided to residents.

The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Executive Director) on 03/01/23 at 9:00 am. She acknowledged the findings. No further information was provided.

C 422 OAR 411-054-0090 Fire and Life Safety: Training for Residents

On 3/9/2023, an all resident meeting was held and the residents were trained on Fire and Life Safety procedures for the community. Topics covered were fire drill procedures, shelter in place, evacuation process and the designated meeting place/fire safe area. The training was documented.

The facility will ensure that each resident is trained on the facility's fire and life safety procedures of the community within 24 hours of move-in and annually thereafter. This instruction will include, but is not limited to, general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or in a fire safe area.

The Executive Director will review each new move-in for compliance and ensure each resident receives the annual training. Executive Director and Maintenance Director will monitor the correction of this deficiency and ensure it is completed per rule ongoing.

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

Refer to C 374, C 610, C 613 and C 615

C 455 OAR 411-054-0105 (2-4) Inspections and Investigation

Facility understands that it failed to ensure their relicensure survey plan of correction was implemented and satisfied the department.

The facility will ensure that this plan of correction is satisfied and that rule contained herein is met and continues to be met.

The Executive Director will monitor on a monthly basis and will be responsible to see that the corrections are completed and monitored now and going forward.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common-use areas were maintained in good repair, and measures were taken to prevent the entry of pests. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 02/28/23. The following issues were identified:

1. The pathways on each side and the rear of the building had multiple drop-offs of up to approximately three inches, measured from the concrete to the planting bed surface. These drop-offs created potential hazards for residents.

2. Window screens were missing from the following windows:

* Adjacent to the exit door near Room 129;

* Two windows in the second floor laundry room; and

* Two windows in the second floor puzzle area.

The lack of window screens could allow for the entry of pests when the windows were opened.

The building was toured with Staff 1 (Executive Director) on 03/01/23 at 11:30 am. She agreed with the findings.

C 610 OAR 411-054-0300 (3)(a-h) General Building Exterior

1. To ensure resident safety, the pathways on each side and the rear of the building will be evaluated and have a stable material placed in the multiple areas noted during the survey to eliminate the three inch drop-offs.

2. The facility will evaluate all windows in the community and install screens where needed. Survey findings showed the following:

- Window adjacent to the exit door near Room 129.

- Two windows in the second floor laundry room.

- Two windows in the second floor puzzle area.

The Maintenance Director will ensure that all window screens are in place and that they are in good condition during his monthly community walk through.

The Executive Director will monitor the correction of this deficiency and compliance ongoing.

Based on observation and interview, it was determined the facility failed to ensure facility grounds were kept orderly and free of refuse and measures were taken to prevent the entry of pests. This is a repeat citation. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 06/26/23. The following issues were identified:

a. A window on the first floor (adjacent to the exit door and room 129), and a window in the second-floor laundry room (left side corner window) was broken which prevented the window from safely opening/closing. Both windows had gaps between the windowpane and frame which prevented the window from closing all the way and the screens on both windows were partially falling off.

b. Litter and refuse were observed in the following areas:

* Scattered on the ground around the dumpster area;

* A garbage can with a cigarette ashtray covering (in the back of the building) was overflowing; and

* Multiple pieces of discarded furniture was piled up in the back of the building and near the kitchen service door.

The building was toured with Staff 11 (Maintenance Director) on 06/26/23 at 11:45 am. He acknowledged the findings.

C 610 OAR 422-054-0300 (3)(a-h) General Building Exterior

a.  

- A window on the first floor (adjacent to the exit door and room 129), and a window in the second-floor laundry room had broken spring guides that allow the window to open/close safely.

Both windows had gaps between the window pane and frame which prevented the window from closing all the way and the screens on both were partially falling off.

b.

- Litter and refuse were observed

- Scattered on the ground around the dumpster

- A gargabe can with a cigarette ashtray covering was overflowing

- Multiple pieces of discarded furniture was piled up in the back of the dumpster area and near the kitchen service door.

The facility will repair the spring guides in the two windows as well as make repairs to eliminate the gap in the windows so that they open and close safely and completely. Screens will also be reinstalled correctly.

All furniture has been removed from the dumpster area and litter/refuse has been cleaned up.

To ensure compliance going forward, the Maintenance Director at the facility will make sure that window safety and function checks are included on monthly walkthroughs of the community. The exterior dumpster area will be checked daily to ensure no refuse is on the ground and that no furniture or other discarded items are present.

The Maintenance Director and Executive Director will be responsible to see that these corrections are completed and monitored.

Based on observation and interview, it was determined the facility failed to maintain the interior materials and surfaces in good repair. Findings include, but are not limited to:

The interior of the facility was toured on 02/28/23. The following issues were identified:

a. The doors and/or door frames of Rooms 112, 114, 203, 220, 222, 226, 228 and the second floor laundry room were gouged or scuffed.

b. The corners of walls to the left of the fireplace in the dining room and across from Room 101 were damaged, exposing plaster or the wall frame.

c. The weather seal around the door leading to the second floor porch was partially detached.

The building was toured with Staff 1 (Executive Director) on 03/01/23 at 11:30 am. She agreed with the findings.

C 613 OAR 411-054-0300 (4)(d-i) General Building: Doors-Walls, Cleanable

a. Facility will repair the following gouged or scuffed doors and/or door frames of rooms 112, 114, 203, 220, 222, 226, 228 and the second floor laundry room.

b. Facility will repair the exposing plaster and/or wall frame of the damaged corners on the walls to the left of the fireplace in the dining room and across from Room 101.

c. Facility will replace the damaged weather seal around the door leading to the second floor porch.

Executive Director and Maintenance Director will monitor the corrections for this deficiency and will do a monthly walk-thru of the community to identify the need for any future repairs.

Based on observation and interview, it was determined the facility failed to maintain the interior materials and surfaces in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured with Staff 11 Maintenance Director) on 06/26/23 at 11:45 am, and the following issues were identified:

* The doors and/or door frames were gouged, had black scuff marks, peeling paint and exposed wood (Resident Rooms 114, 216, 222, 225, 226, 227, 228, 229, first floor and second floor patios, second floor laundry room, and second floor elevator);

* There was a two-inch-long hole in the wall underneath the handrail near room 227;

* There was a missing floor threshold upon entering the movie room/pool table room; and

* Multiple wall corners throughout the facility were gouged with missing paint and exposed sheetrock.

The need to ensure the buildings interior was kept in good repair was discussed with Staff 11. He acknowledged the findings.

C 613 OAR 411-054-0200 (4)(d-i) General Building: Doors-Walls, Cleanable

- The doors and/or door frames were gouged, had black scuff marks, peeling paint and exposed wood (Resident rooms 114, 216, 222, 225, 226, 227, 228, 229, first floor and second floor patios, second floor laundry room, and second floor elevator.

- A two inch long hole under handrail near room 227.

-Missing floor threashold in entry way to movie/pool room.

- Multiple wall corners throughout the facility were gouged with missing paint and exposed sheetrock.

The facility will assess the doors and/or door frames,- as well as walls/wall corners through out the facility that were identified, and make the needed repairs so that all areas are in good repair and free of gouges, scuff marks, peeling paint, exposed sheetrock and exposed wood.

The hole on the underside of the handrail will be repaired and a new threashold will be placed at the entry to the movie/pool room.

The Maintenance Director of the facility will do weekly walkthroughs to identify any new damage to interior surfaces and make any needed repairs.

The Executive Director will be responsible to see that corrections are completed and monitored going forward.

Based on interview and record review, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. Findings include, but are not limited to:

The interior of the facility was toured on 02/28/23. Windows in the common areas and resident rooms on the second floor of the building had sill heights less than 36 inches and could be opened by residents. The facility used a small metal device which attached to the window frame with a thumb screw to limit how much a window could be opened.

Windows in the activity room, the puzzle area, the library area, and one of two windows in Resident room 211 lacked limiting devices.

The building was toured with Staff 1 (Executive Director) on 03/01/23 at 11:30 am. She agreed that some windows were lacking a device which limited how much a window could open in order to prevent accidental falls.

C 615 OAR 411-054-0300 Resident Units

To ensure the safety of the residents, and prevent accidental falls, the facility will install limiting devices to all windows above the first floor that have sill heights less than 36 inches. These devices will prevent the window from opening to where a resident could fit through and potentially fall. The following windows were identified as missing limiting devices.

- Windows in the activity room, the puzzle area, the library area, and one of two windows in Resident Room 211

The facility will conduct a full inspection of all windows above the first floor, in common areas and resident apartments with a sill height of less than 36 inches. Any windows that are identified and not listed above will have a limiting device installed.

The Executive Director will monitor the correction of this deficiency. The Maintenance Director will conduct quarterly inspections of all windows above the first floor to ensure limiting devices remain intact.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and above the first floor. This is a repeat citation. Findings include, but are not limited to:

The interior of the facility was toured with Staff 11 (Maintenance Director), on 06/26/23 at 11:45 am.

Five windows in the second floor activity room and four windows in the second floor library area, lacked limiting devices.

Staff 11 acknowledged some windows were lacking a device which limited how much a window could open in order to prevent accidental falls.

C 615 OAR 411-054-0300 (5) Resident Units

Five windows in the second floor activity room and four windows in the second floor library area lacked limiting devices.

The facility will install limiting devices on the windows identified and ensure that all other windows have the devices as well.

Maintenance Director will conduct a daily walk through of the community to ensure all limiting devices are in place.

The Executive Director and Maintenance Director will be responsible to see that the corrections are completed and monitored.