The findings of the re-licensure survey, conducted 05/16/22 through 05/18/22, 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 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 first re-visit to the re-licensure survey of 05/18/22, conducted 12/12/22, are documented in this report. The survey was conducted to determine compliance with 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 second revisit to the re-licensure survey of 05/18/22, conducted on 05/09/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs Division 54 for Residential Care and Assisted Living Facilities.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

Resident 6's current service plan, dated 4/18/22, noted the resident smoked and used supplemental oxygen.

During observations on 05/17/22 at 3:45 pm, Resident 6 was observed in the smoking area with five other residents.  Resident 6 had a nasal cannula in place attached to a portable oxygen tank, and was observed lighting and smoking cigarettes.

The tank of concentrated oxygen and tubing next to an open flame created a fire hazard.

Staff were notified, and at 3:50 pm removed the oxygen tank from the smoking area.  Resident 6's service plan was updated to require staff assistance when smoking.

The following morning, on 05/18/22 at 8:15 am, Resident 6 was observed in the smoking area, with oxygen tank and oxygen tubing, lighting and smoking cigarettes.

Staff were notified, and by 8:20 am removed the oxygen tank from the smoking area.

In interview on 05/18/22, the need to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (Executive Director) and Staff 2 (RN). They acknowledged the findings.

1. Changes of service plan were implemented for the safety of the resident and smoking precautions included. a: Cigarrettes are kept in a safe place where resident can ask for one when she is ready to smoke. b:Staff needs to take oxygen off 20 minutes before resident is to go outside to smoke. c: resident is able to go outside with supervision and smoke.

2. RN to complete smoking evaluations quarterly or immediately if a health or safety risk is identified.

3. Inservices held on 5/25/2022 with all of our Nursing staff.

4.RN and RCC are to monitor daily.

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

1. Observations of the central kitchen on 05/16/22 revealed the following areas were in need of cleaning or repair:

* The walk in freezer door was damaged, hinges corroded with metal flaking off, and ice and water had accumulated around the bottom of the door;

* The compressor inside the freezer had accumulated ice that blocked airflow; and

* Several containers in the freezer and walk in were undated, with several containers not closed or covered.

2. Observations of both first floor kitchenettes on 05/16/22 revealed the following:

* A build-up of brown matter inside the cabinet underneath both sinks;

* Multiple broken or loose cabinet hinges; and

* Multiple dining room chairs were tilted forward (were not seated level).

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (ED),  Staff 7 (Environmental Services Director), and Staff 9 (Executive Chef). They acknowledged the findings.

1. Walk in freezer-

Scotts heating and air conditioning company has been called to evaluate the freezer unit and provide necessary repairs to make the unit functional. Parts are currently on order. This will also include repair on the freezer door with replacing the sweep to keep ice from building up. The rubber seal around the door is also to be replaced. Parts are supposed to be delivered 6/8/2022.

2.The hinges are to be replaced on the freezer door. A side plate is be placed on the coil to prevent icing from acumulating on the coil.

3. It will be the responsibility of the Environmental service Director to ensure these tasks are done with efficiency.

4.Executive Chef will be doing daily walk throughs to ensure all containers are closed, covered, and dated.

5. Check list for staff being made so staff can also check and make sure everything is dated, covered, and closed.

6.Executive Chief and Enviromental Service Director will sign a check list for the following:

a.Check all cabinets weekly to ensure cleanliness.

b. Check all hinges weekly to ensure the cupboards are fastened securely.

c.Environmental Service Director to work on repairing chairs where they are more level.

Based on observation, interview, and record review it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The kitchen was toured with Staff 9 (Executive Chef) on 12/12/22.

Observations of the facilities kitchen, food storage areas, food preparation and food service revealed:

* Splatters, spills, drips, and debris noted on:

- Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen and cabinets in the dining rooms;

- Storage shelves and metal rack shelving throughout the kitchen and in the walk in refrigerator and freezer;

- Cages of fans in the refrigerator;

- Food storage bin handles, lids, and surfaces;

- Interiors of cupboards and drawers throughout the kitchen and dining rooms;

- Walls throughout the kitchen;

- The dishwashing area walls, floors, drain, and equipment;

- Floor drains throughout the kitchen;

- Cove base;

- Both sides of the range, grill, oven, and warming/confection oven;

- Behind and underneath appliances;

- Baking rack shelving;

- The stand mixers;

- The blender;

- Food processor;

- The cage and blades of fans;

- Garbage can surfaces; and

- Carts.

* The laminate shelving throughout the kitchen and dining rooms was damaged, creating un-cleanable surfaces.

* The surface of the stand mixer was corroded with metal chipping off.  

* The cove base throughout the kitchen was damaged creating areas filled with debris.

The areas in need of cleaning and repair were observed with Staff 1 (Executive Director). She acknowledged the findings.

Deep cleaning of the kitchen in its entirety will be done immediately.

Hired staff to deep clean kitched twice a week to maintain cleanliness.

Audit/Check off Sheet with areas to be cleaned routinely made for all staff in kitchen.

Covers being ordered for kitchen aides.

Shelving will be fixed by ESD and have a cleanable surface.

Painting of all racks in kitchen and freezer.

Regrouting of all chipped cove base throughout the kitchen.

Steam cleaning of tile flooring with Klines every 90 days

Cupboard doors are being rebuilt and replaced in dining rooms.

Counter top and backsplash being replaced in smaller dining room.

Based on interview and record review, it was determined the facility failed to ensure orders were carried out as prescribed for all medications and treatments the facility was responsible to administer, for 1 of 5 sampled residents (# 1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 04/2022 with diagnoses including stroke with left side hemi-paresis.

Resident 1's 05/1/22-05/16/22 MAR and current signed physician orders revealed the following:

* Physician orders instructed staff to hold Prazosin (for urinary retention) if blood pressure was less than 100/60. There was no documented evidence the facility was checking Resident 1's blood pressure prior to administering the medication;

* Baclofen (for muscle spasms) was not administered for 25 doses;

* Omeperzole (for stomach acid) was not administered for 22 doses;

* Prednisone (for arthritis) was not administered for 12 doses; and

* There were no signed orders for PRN Bisocodyl suppository.

On 05/17/22, Staff 10 (MT) confirmed the Baclofen and Omeperzole were received from the pharmacy on 05/11/22, the day s/he sent a fax to the pharmacy. Staff 10 stated the Prednisone still hasn't been received and the pharmacy faxes go to the Resident Care Cordinator for resolution.

On 05/17/22, Staff 3 (RCC) reported the MT's were supposed to send faxes daily for medications that haven't been received and notify the RCC's if there was an ongoing issue.

Resident 1's MARs and orders were reviewed with Staff 1 (ED), Staff 2 (RN), and Staff 3 on 05/18/22. They acknowledged the findings.

1.Blood pressure checks were immediately implemented in the MAR with following parameters:HOLD IF BP IS BELOW 100/60 AND NOTIFY MD

2.Medications will be reordered according to our policy as follows:

a. Reorder medications form the pharmacy 7 days prior to running out or as directed by your Health Service Director. Note: When re-ordering PRN medications, you will need to consider how frequently the resident normally takes the medication in order to determine how early to reorder.

b. Keep a log of medications which have been reordered so that everyone who has responsibility can see if a medication has been reordered.

c. If medications are not received within 3 days of ordering, call the pharmacy or family ember to find out where they are and how you will be able to get them prior to

running out. Any special circumstances regarding a particular resident's medications and reordering instructions should be noted on the Service Assessment. (Note: In Washington, a Family Assistance with Medications Contract is required.)

d. When medications are received, check to make sure the correct prescription has arrived prior to placing it into storage.

e. Indicate the medications have been received on the log.

4. Med techs are resposible for the ordering, RCC is responsible to check once a week to make sure medications are ordered and delivered properly according to the MAR, also overseen by RN.

5. RCC and RN are to check every order to ensure the order has been checked three times and in the MAR correctly.

Based on interview and record review, it was determined the facility failed to ensure all required elements were documented for fire drills in accordance with Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to:

Review of fire drill and fire and life safety records from December 2021 through March 2022  identified the following:

* The facility failed to provide fire and life safety instruction to staff on alternate months: and

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

* Number of occupants evacuated; and

* Alternate routes used during fire drills were not documented.  

The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Executive Director) and Staff 7 (Environmental Service Director). They acknowledged the findings.

1. Unnannounced fire drills will be conducted every other month by Environmental Service Director. A written document has been made to record the following:

a.Date and time of day drill happens

b. Location

c. Escape route used.

d. Problems we may have encountered.

e. Time it took to evacuate

f. Staff who participated

g. Number of residents who we have evacuated.

2. Fire and life safety training will beconducted every other month by Environmental Service Director. We will discuss the following:

a. Alternate exit routs

b. Evacuation capability

c. The ability of the residents to evacuate and the assistance provided by staff.

d. Fire life saftey protocol

e. RACE

f. PASS- with actual fire extinguisher training

Based on interview and record review, it was determined the facility failed to provide Fire and Life Safety instruction to residents annually.  Findings include, but are not limited to:

Fire drill records from 12/2021 through 03/2022 were reviewed.

The facility lacked documentation that residents were being instructed on fire and life safety procedures at least annually and more if needed.

The requirements for Fire and Life Safety instruction for residents were reviewed with Staff 1 and Staff 7 on 05/17/22. They acknowledged the findings.

1.Training for residents will be conducted within 24 hours of admission and will be documented and put in our fire life safety book.

2.We will schedule a yearly training for residents and it will also be documented in our fire life safety book. 3.Training will be conducted by  Enviornmental service director and overseen by the ED.

Based on observation and interview, 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 240.

Currently reviewed the plan and all  aspects of the survey POC will be implemented.

Based on observation and interview the facility failed to have handrails secured to the wall in resident use corridors. Findings include, but are not limited to:

The interior environment of the facility was toured on 05/16/22 at 1:30 pm. The facility is a two story assisted living community. The following was identified:

* Multiple sections of handrails on the first and second floors were not secured to the wall or were loose.

The facility was toured and findings were shown to Staff 1 (ED) and Staff 7 (Environmental Services Director on 05/17/22 at 8:58 am. They acknowledged the findings.

1. Handrails were immediately tightened to fasten them securely to the wall.

2. Environmental service director will do a daily walk through to check handrails.

3. Housekeeping will do a monthly check on handrails and document.

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

The facility was toured on 05/16/22 at 1:30 pm. The following areas required cleaning or repair:

*  There were gouges and scratches to all exit doors, multiple resident unit doors, shower room doors;

* There were white stains on the hallway carpet near the second floor nurses station and multiple dark spots throughout the entire carpet on the second floor; and

* There were dark spots and debris built-up on the carpet in the first and second floor elevators.

The facility was toured and findings were shown to Staff 1 (ED) and Staff 7 (Environmental Services Director) on 05/17/22 at 8:58 am. They acknowledged the findings.

1.Kick plates being ordered for doors to help prevent scratches on doors. These will be installed by ESD as soon as we receive them.

2.Second floor carpet will be replaced due to multiple bleach stains and other stains that cannot be removed.

This will be overseen by ESD.

3.Elevator floor has been replaced by ESD and vinyl planking has been installed.