The findings of the relicensure survey, conducted 12/09/21 through 12/10/21, 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 for 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

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 revisit to the re-licensure survey of 12/10/21, conducted 03/08/22 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 ensure an incident of suspected abuse was immediately reported to the local SPD office for 1 of 1 sampled resident (#1) reviewed with a resident-to-resident physical altercation. Findings include, but are not limited to:

During the acuity interview on 12/09/21, Resident 1 was identified to be involved in a resident-to-resident physical altercation.

Review of Resident 1's record revealed the following:

* An incident report dated 11/20/21 identified Resident 1 was upset and arguing with another resident. Resident 1 pushed the other resident down two times. The residents were separated.

Resident 1 was placed on alert charting and interventions were developed; however, there was no documented evidence the incident had been reported to the SPD office.  

During an interview on 12/10/21, Staff 1 (Administrator) stated she should have reported the incident to the SPD office, but did not. The surveyor requested the incident be reported to the local SPD office. The surveyor received confirmation of the report to the SPD office on 12/10/21.

The need to ensure resident-to-resident physical altercations were investigated and reported to the local SPD office as appropriate was discussed with Staff 1 and Staff 2 (RN) on 12/10/21. They acknowledged the findings.

No matter how minor the incident, we will repot it to APS within 24 hours of the incident.

Administrator will start an investgation and report the incident to APS within 24 hours of the incident.

Quarterly

Administrator

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair and the refrigerator temperature was within an acceptable range, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 12/09/21 at 9:50 am, the facility kitchen was observed to need cleaning and repair in the following areas:

a. The facility had three refrigerators. Refrigerator #1, located in the kitchen, did not feel cold when opened. Food, including protein-based food items, did not feel cold when touched. The internal thermometer read 55 degrees F. At 10:15 am, the surveyor showed Staff 1 (Administrator) the refrigerator's thermometer and low temperature. She stated the refrigerator "started acting up on Tuesday [12/07/21]". Calls had been placed to repair it. The facility was waiting for "them [repair service] to contact us." The surveyor explained the protein-based foods needed to be kept at or below 41 degrees to ensure food was stored safely. The surveyor instructed Staff 1 to dispose of all protein-based foods that had not been kept at a safe temperature. Staff 1 acknowledged the concern and immediately discarded all protein-based foods within refrigerator #1. All other food items were transferred to the other refrigerators.  

b. Food spills, splatters, debris, dirt and black matter was observed on or underneath the following:

* Interior and exterior of several cabinets and drawers;

* Underneath the one compartment and two compartment sinks; and

* Floor perimeter and underneath a floor mat in front of the sink.

c. The following areas needed repair:

* The swinging door leading into the kitchen had multiple areas with peeling paint;

* The cabinet underneath the two-compartment sink had a warped, degrading wood lower shelf that bowed inward. Additionally, the paint was peeling;

* The flooring around the perimeter of kitchen walls and cabinets lacked a baseboard. A gap was present, and an accumulation of dirt and food matter was visible; and

* A cabinet door to a lower corner cabinet was not attached and fell off when opened.

The areas that required cleaning and repair were observed and discussed with Staff 1 on 12/09/21 at 11:20 am. The findings were acknowledged.

1.a. A new refrigerator has been purchased; because of delays its estimated delivery date is now 01/28/2022.

b. A contractor has been contacted to repair cabint door, under the sink, install new moldings around the door and baseboards in the kitchen.

c. All doors and door jambs will be inspected and touched up as needed throughout the facility'

2. All issues found in the quarterly facility walkthrough inspection will be immediately addressed and all repairs will be completed as sone as possible.

3. Quarterly

4. Adminstrator

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 3 sampled residents (#1) whose medications were reviewed. Findings include, but are not limited to:

Resident 1 moved into the facility in 09/2021 with diagnoses which included insulin dependent diabetes.

S/he had orders for CBGs to be checked four times a day, Lantus insulin once a day, and Novolog sliding scale insulin to be given at lunch, dinner and bedtime in varied amounts based on results of the CBGs.

On 10/01/21, Staff 2 (RN) faxed the resident's nurse practitioner that "We will notify you via phone call for all blood sugars less than 70, and give orange juice followed with protein (cheese, milk, peanut butter), and repeat blood sugar - unless otherwise indicated."

The MARs, reviewed from 11/01/21 through 12/09/21, lacked medication specific instructions related to CBGs and insulin administration; including when to call the prescriber or nurse, when to give orange juice and a protein snack, and when to perform repeat CBGs.  

The need to ensure the MAR was accurate and provided medication specific instructions related to insulin administration was discussed with Staff 1 (Administrator) and Staff 2 on 12/10/21. They acknowledged the findings.  

1. It is our policy for the RN to avoid taking a verbal Doctors order unless absolutely nessesary. In the event that it is nessesary for the RN to take a Doctors order over the phone, it is the responsibility of the RN to follow through to make sure a signed order has been receive within 24 working hours.

It is the responibility of the RN to clearly relay the orders to the staff with all parameters included.

2. The Administrator must be informed that a verbal order has been taken and will ensure the RN follows through with the task within the 24 working hours from the date the verbal order was received.

3. Every time a verbal order is taken.

4. Adminstrator/Ex-Management

Based on interview and record review, it was determined the Administrator failed to have 20 hours of documented Department approved continuing education credits each year. Findings include, but are not limited to:

On 12/10/21, Staff 1 (Administrator) was asked to provide documentation that she had completed 20 hours of CEU's (continuing education credits) from 05/2020 through 05/2021.  Staff 1 provided documentation of three CEU hours and acknowledged she had not completed the required continuing education.

Administrator will take all nessesary courses to make sure all required CU's  are up to date.

The Administrator will continue electronic education courses and attend Sonar meetings to maintain appropiate CU's.

Semi-annually

Ex-Managment

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation and pre-service dementia training was completed prior to beginning work in the facility for 1 of 1 staff (#3) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 12/09/21.

* Staff 3 (CG) was the most newly hired staff person at the facility. Staff 3, hired 08/2020, lacked documented evidence of having completed pre-service orientation and pre-service dementia training.

The need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator) on 12/09/21 at 5:30 pm. She acknowledged the findings.

1. Training and required certificates have been completed and documentation has/will be put in the employee file.

2. All new employees are required to complete 18 hours of hands on training. The new employee must complete all dementia on-line courses, have CPR and First aid certifications plus food handlers card prior to starting the hands on training.

All training will be signed off as each segment is completed to ensure the training has been correctly completed.

3. The Administrator will review the hire packet to make sure all training and paperwork has been completed and is included in the employee file.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 caregiving staff (#3) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed on 12/09/21.

There was no documented evidence Staff 3 (CG), hired 08/2020, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

Additionally, there was no documented evidence Staff 3 had completed First Aid certification and abdominal thrust training.

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) on 12/09/21. She acknowledged the findings.

1. All employee files are being checked to ensure all CPR, First Aide and Food Handlers certificates/cards are current and upto date.

2. All new employees are required to complete 18 hours of hands on training. The new employee must complete all dementia on-line courses, have CPR and First aid certifications plus food handlers card prior to starting the hands on training.

All training will be signed off as each segment is completed to ensure the training has been correctly completed.

3. The Administrator will review the hire packet to make sure all training and paperwork has been completed and is included in the employee file.

4. Administrator

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 4 and 5) whose training records were reviewed. Findings include, but are not limited to:

a. Staff 4 (CG), hired 03/2018, failed to have documented evidence of completing 12 hours of required in-service training, including six hours related to the care of the dementia resident, between 03/2020 - 03/2021.

b. Staff 5 (Admin Assistant/MT), hired 09/2019, completed three of the 12 hours of required in-service training, including six hours related to the care of the dementia resident, between 09/2020 - 09/2021.

The need to ensure staff completed required annual in-service training, based on anniversary dates of hire, was reviewed with Staff 1 (Administrator) on 12/09/21 at 5:30 pm. She acknowledged the findings. No further information was provided.

1. Training and required certificates have been completed and documentation has/will be put in the employee file.

2. All new employees are required to complete 18 hours of hands on training. The new employee must complete all dementia on-line courses, have CPR and First aid certifications plus food handlers card prior to starting the hands on training.

All training will be signed off as each segment is completed to ensure the training has been correctly completed.

3. The Administrator will review the hire packet to make sure all training and paperwork has been completed and is included in the employee file.

4. Administrator

Based on interview and record review, it was determined the facility failed to conduct unannounced fire drills every other month at different times of the day, evening and night shifts, failed to include required components on fire drill records, and failed ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records, reviewed between 06/2021 - 11/2021, revealed the following:

a. One fire drill had been completed during the six-month time frame reviewed. Fire drill records lacked the following components:

- Escape route used;  

- Problems encountered and comments relating to residents who resisted or failed to participate in the drill; and

- Evacuation time period needed.

b. Fire and life safety instruction was not provided to staff on alternate months.

The requirements regarding fire drills and fire/life safety instruction for staff was reviewed with Staff 1 (Administrator) during interviews on 12/09/21 and 12/10/21. She acknowledged the findings. No further information was provided.

1. All documentation of Fire Drills and training will be kept in a folder in the Administrators office and made avaliable upon request.

2. Fire Drills will be held the evening before or the day of our in-service monthly training. All Fire drills will be reviewed at the time of our in-service meeting to improve our processes. Signatures by staff are required to prove attendance. Annual training for staff and resident will be documented and require.

3. All fire Drills will be held bi-monthly by the Administrator or appointed staff member.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:

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

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

* Documentation that annual fire and life safety training was provided to residents, including all required training topics; and

* Alternate exit routes were used during fire drills.

The need to ensure residents received fire and life safety training within 24 hours of admission, were re-instructed at least annually, and alternate exit routes were used during fire drills was discussed with Staff 1 (Administrator) on 12/10/21 at 9:35 am. She acknowledged the findings. No further information was provided.

1. All current residents and staff members wiil be given an overview of the Fire safety rules, evacuation routes and gathering area (Copies upon request). They will also be shown where schematics of the evacuation route and meeting area are located.

2.  All new Admits and new employees will be given a copy of the fire safety rules, policies and procedures at time of admit or hire. On going training with the employees during bi-monthly fire drills and annual refresher training of the residents will correct this violation.

3. Training and Fire drills will be evaluated Semi-annually.

4. Ex-Managment

Based on observation and interview, it was determined the facility failed to ensure exterior grounds were orderly and free of litter and refuse. Findings include, but are not limited to:

The facility grounds were toured on 12/09/21 and the following was observed:

* Cigarette butts and tobacco residue littered the porch and side tables in the front of the building; and

* Trash debris and broken chairs were visible on the deck off of the dining room.

The building exterior was toured with Staff 1 (Administrator) on 12/09/21 at 11:20 am. She acknowledged the findings.

1. All cigarette butts and ash have been cleaned up immediately. The patio will be pressure washed to remove coffee and ash stains.

2. Near the end of each shift it is the responsabiliy of the leaving Resident Aide to empty ashtrays and make sure the patio is presentable. Thorough cleaning will be conducted as needed.

3.The area will be evaluated monthly at the time of the facilities monthly inspection.

Administrator

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

Observations of the facility on 12/09/21 revealed the following:

* Flooring between the kitchen and medication area, and a storage room (off of the kitchen) had several areas that were missing vinyl, rendering the surface uncleanable;

* The door jamb between the kitchen and dining room had a section that was loose and coming apart from the wall;

* Common bathrooms had scraped door jambs and were missing paper towels, soap and toilet paper;

* Rooms 1, 4, 5, 6, 9 and 10 had scraped doors and/or jambs; and

* The hallway and closet (next to washer and dryer in main hallway) had a strong urine odor. When the closet was opened, an uncovered plastic barrel was visible inside. The barrel had a strong urine odor that permeated the closet.

The surveyor toured the environment with Staff 1 (Administrator) on 12/09/21 at 11:20 am. She acknowledged the urine odors and areas that needed to be repaired.

1.

        a. An outside Contractor has been contacted                    .            repair the vinyl flooring in the utility room.

        b. All door jambs will be inspected and touched .   .            up as needed.

        c. Appropriate hygiene needs have been placed    .            in common bathrooms.

        d. A deep clean has been completed in the          .  .            linen closet and laundry storage room. All                   .            odors have been eliminated.

2.  A formal training will be conducted will all employees to ensure all soiled linen and clothing will be properly cared for prior to them being put in the storage barrel for final cleaning. the lid is the remain on the barrel at all times ti isolate unwanted odors.

3. Spot checks will be done throughout the month to ensure the resident aides are following procedures.

4. Administrator

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 12/09/21 showed that the main entrance/exit door did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The surveyor toured the environment with Staff 1 (Administrator) on 12/09/21 at 11:20 am. She acknowledged the front entrance/exit door did not have a working alarming device or other acceptable system to provide security and to alert staff when residents exited the building.

1. An outside Contractor has been contacted to repair the door alarms.

2. Once the system has been repaired, the system will be checked at the time of the monthly facility walkthrough.

3. monthly

Administrator