The findings of the re-licensure survey, conducted  02/06/23  through  02/08/23 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 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

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 02/08/23, conducted 08/07/23, 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 and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure residents received services in a manner that protected their privacy and dignity for 10 of 13 unsampled residents. Findings include, but are not limited to:

1. A group of seven unsampled residents were interviewed on 02/07/23 at 10:45 am. Six residents reported staff did not wait for the resident to respond prior to staff entering their room.

2. Observations of lunch tray delivery to unsampled residents' apartments were made on 02/07/23 at 12:42 pm. In four of six deliveries, the caregiver said "knock, knock," opened the resident's door and entered the room. The resident did not have the opportunity to invite the caregiver into his/her apartment.

The need to ensure residents received services in a manner that protected privacy and dignity was discussed with Staff 1 (ED), Staff 3 (RN) and Staff 4 (RCC) on 02/08/23 at 1:24 pm. They acknowledged the findings.

C 200  

1.  All staff will receive additional training in procedures for entering resident's apartments.  In addition new staff will receive appropriate training in procedures for entering a resident's apartment.

2.  Training with current staff has been completed at shift changes, 2/13, 2/14, and 2/15/2023.  This included all staff on the schedule.  Completed 2/15/2023.   A detailed training with all staff occured at the All Staff Meeting, 2/22/23

New staff will receive training at "new hire orientation".  All staff will receive ongoing reminders and training as necessary, and will be included at the monthly, all staff meeting.

3.  This area will be evaluated daily, with training and correction ongoing each day, if needed.

4.  Corrections are to be completed and monitered by RCC, HSD, and ED.

Based on observation, interview and record review, it was determined the facility failed to ensure residents were monitored consistent with their evaluated needs and service plan for 1 of  3 sampled residents (#5) whose records were reviewed. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 2021 with diagnoses including arteriosclerotic heart disease.

The 12/19/22 evaluation and 12/28/22 service plan were reviewed and noted the resident was a bed bound, hospice patient who was at risk for weight loss.

The service plan noted the facility would monitor the resident's weight as tolerated. The facility obtained the resident's weights as follows:

* 08/10/22 - 155 pounds; and

* 09/10/22 - 156 pounds pounds.

There was no documented evidence the facility made attempts to  monitor the resident's weight after 09/10/22.

In interview on 02/07/23, Staff 3 (RN) reported the resident had been resistant to being transferred out of bed for several months and frequently refused to drink the nutritional supplements offered by the facility. She acknowledged the most recent service plan lacked any new interventions to address the risk for weight loss or instructions for monitoring the resident.

The facility's failure to monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 1 (ED) and Staff 3 on 02/08/23. They acknowledged the findings.

C 270

1.  Staff will measure the upper arm (bicep) circumference, bilaterally once every 2 weeks.  If a difference of more than 2 cm is found, staff will notify RN immediately.

Staff will meet with 209 to learn food preferences.  DSM and a PCA will meet with 209 when filling out a daily menu, and go over the alternative choices on the menu, and will also find out what personal choices he may have that are not listed.   Staff will notify the kitchen daily of 209's meal and food choices.

2.  RN will implement the process of upper arm measurement when it is recognized that getting accurate weights is no longer an option.  Arm measurements will become a part of the service plan, and the task will be reviewed quarterly.  209's meal options and choices will be reviewed with him daily as part of his updated care plan.

3.  Arm circumference will be measured bi-weekly.

Food choices service plan will be evaluated quarterly at minimum.

4.  RN will be responsible for changes to the service plan and will moniter.  ED will ensure that all is implemented and monitered as stated.

Based on interview and record review, it was determined the facility failed to ensure pre-service dementia training was completed prior to providing services to residents, for 2 of 3 newly hired staff (#s 12 and 13). Findings include, but are not limited to:

Facility's training records were reviewed with Staff 2 (Business Office Manager) on 02/08/23.

Staff 12 (CG) hired on 07/18/22 and Staff 13 (CG) hired on 08/01/22, lacked documented evidence of completing the following:  

Pre-service dementia training including:

* Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms;

* Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses;

* Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; and

* Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia.

The need for staff to complete the required pre-service dementia training before working with residents was reviewed with Staff 1 (ED) and Staff 3 (RN) on 02/08/23. They acknowledged the findings.

C 370

1.  All staff must complete and print certificate for required training in Pre-Service Dimentia and Pre-Service Infection prevention, prior to training on the floor.  Staff hired 8/1/22, was terminated on 2/13/23.  Staff hired on 7/18/22, will complete Pre-Service Dementia training by 3/01/23, and will not be scheduled until after the training is complete.  

2.  OM and RN will work together to ensure as part of orientation, Pre-Service Dementia, and Pre-Service Infection Prevention is completed and certificates are printed and filed.  RN and RCC will not schedule an employee until all training is complete and corresponding certificates are filed.

3.  An evaluation will be conducted Quarterly and verification will be made that all training is current.

4.  In cooperation, OM, RCC, HSD, ED will complete and monitor.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 9, 12 and 13) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Training records were reviewed with Staff 2 (Business Office Manager) on 02/08/23 and identified the following:

1. Staff 9 (MT) hired on 11/15/22, lacked documentation of demonstrated competency in:

* First Aid/Abdominal Thrust.

2. Staff 12 (CG) hired on 07/18/22, lacked documented evidence of demonstrated competency in :

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and

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

3. Staff 13 (CG) hired on 08/21/22, lacked documentation of demonstrated competency in:

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition; and

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

The need to ensure staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 3 (RN) on 02/08/23. They acknowledged the findings.

C 372

1.  All staff must complete online CPR training and show competency in First Aid/Abdominal Thrust, prior to being scheduled.  This process will be completed on Day 1, or Day 2 of orentation.  Certificates must be printed prior to bing scheduled on the floor.  Certificates will be filed.  

Staff 9 (MT), hired on 11/15/22,  demonstrated compentency for Abdominal Thrust, on 2/10/23.  

Staff 12 (CG) hired on 7/18/22, has completed PCA and MT compentency and is documented.  (2/17/23).  

Staff 13 (CG)  hired on 8/1/22 was seperated from employment on2/13/23.  This employeee had competed the competency training but in an oversight did not sign the training addendum.

2.  OM and RN will work together to ensure that as part of orientation, Pre-Service Dementia, and Pre-Service Infection Prevention, and all required training is completed and certificates are printed and filed.  RN and RCC will not schedule an employee until all training is complete and corresponding certificates are filed.   

3.  Evaluation will be ongoing, with all staff and newly hired staff.

4.  ED will ensure compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month, included required components on fire drill records, and provided fire and life safety instruction to staff on alternating months. Findings include, but are not limited to:

On 02/07/23, fire drill and fire and life safety training records for the previous six months were reviewed, and the following was identified:

* Fire drills were not consistently completed every other month during the six-month time frame reviewed;

* Fire drill records lacked the following components:

- Escape route used;

- Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

- Number of occupants evacuated; and

- Evidence alternate routes were used during fire drills.

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

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (ED), Staff 3 (RN), Staff 4 (RCC) and Staff 5 (Maintenance Director) on 02/08/23. The findings were acknowledged.

C 420

1.  Fire drills will be conducted monthly.  Documention using the CBC Fire and Life Safety Review form will be used.  The escape routes used,  problems that were encountered with the building or residents, number of occupants evacuated, and evidence of alternate routes used, correcting the rules violation, will be utilized and documented.  In addition to the CBC form,  documention will be entered into and filed using the TELS documention form.  Forms will be uploaded for computer filing by the Maintenance Director (MD).  Fire and Safety instruction will be provided monthly to staff in Monthly staff meetings with proper documentaion.

2.  All Drills will be properly and routinely conducted, as required, to ensure that all staff are properly receiving the necessary instruction and training.

3.  All Fire, Life and Safty will be evaluated on a monthly interval, at a minimum.

4.  MD will ensure all compliance with regulations are met, with the oversight and monitoring of the ED.       

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces, pathways and individual resident patios were maintained in good repair. Findings include, but are not limited to:

Observations of the facility pathways and seating areas on 02/06/23 showed the following:

* Multiple drop-offs of 2-4 inches were noted along pathway edges and resident personal patios at the back of the facility;

* Two sections of the concrete pathway had lifted creating an uneven surface; and

* One side of the concrete ramp located at the resident smoking area had dropped, which created a separation and lip approximately two inches in height.

The need to ensure pathways around the facility, and around the residents' individual patios did not have potential tripping hazards was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 02/07/23. They acknowledged the findings.

C 610

1.   2-4" drop offs will be eliminated.

2.  Rock and soil will be delivered to the facility.  The areas needing attention will be filled with the rock and/or soil as needed to level the areas along the pathways and aound the resident patios.  Reseeding of grass will be completed as necessary.

3.  These areas will be monitered weekly through our First Impressions inspections by the MD. CRD, and ED.

4.  The MD will ensure that these areas are brought into compliance.  The corrections will be completed pending weather conditions, but will be completed by 04/09/23.  The ED will have final responsibility for completion.

C610

1.  Uneven concrete pathways in two locations, and an  uneven ramp on the pathway, near the designated resident smoking area.  Thes areas will be made even with no ledges or dropoffs.  Excessive spaces between concrete slabs, results of shrinking and expanding since construction, will be eliminated.

2.  A cement mix will be used to eliminate the ledges and dropoffs.  The mix will also be used to fill in spaces between concrete slabs.  This mix is a professional cement mixture that will ensure an asthetic appearance and provide a long lasting solution and will eliminate the trip hazard.

3.  MD will repair the hazard.

4.  ED will monitor for future hazards, and ensure the corrections are completed.

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 02/06/23 through 02/07/23 showed the following areas in need of cleaning or repair:

* Multiple dining room chairs had stains of varying sizes on the fabric chair backs;

* Arm chairs in the upstairs common area and in the main lobby had stains and splatters on the arms and seats of varying sizes as well as tears and exposed stuffing;

* The cupboards, drawers and walls in the activity room had spills, stains and splatters.

* The drink station in the dining room had large stains and spills inside the cupboards and drawers had splatters and debris on the inner surfaces;

* The main facility laundry and the resident laundry room on the second floor had cracked linoleum that was separating around the drains and/or at the seams of the floor;

* Scrapes, dings and deep gouges were noted on doors, door frames or nearby walls at Rooms 103, 104, 105, 108, 201, 202, 208, 210, 220, 222 and 225;

* Significant black/red/white stains of varying sizes from a few inches to several feet were noted in the activity room, outside the elevator, in the area in front of the kitchen entrance, outside the dietary managers office, outside the housekeeping door, in front of exterior doors, in hallways throughout the first and second floor in common areas and in front of multiple resident rooms, inside the dining room and inside Rooms 105, 201, 206 and 220;

* Room 216 had a hole in the wall behind the recliner, chipped/scraped bathroom door frame and a brown substance observed on the top and underside of the toilet seat;

* Room 220 had a large section of door frame/molding missing on the interior portion, large dings/chips and missing pieces of plaster to the interior of the front door and along walls in the room;

* Counter top surface lifting up and pulling away from the sink area in the whirlpool room and chips/dings/scrapes noted to the wood surface at the outside of the whirlpool tub;

* Two wood benches in the resident outdoor area had cracked slats or detached metal supports;

* Siding above the dining room over hang was crumpled, lifting and pulling away from the building;

* A mesh box encasing multiple dryer vents on the outside of the building near the activity room entrance, was covered in a thick layer of lint on all sides; and

* Multiple dirty cushions, rags, a broken table and old filters were observed on the patio and in the borders outside the activity room and dining room.

The areas in need of cleaning and repair were shown to and discussed with Staff 1 (ED) and Staff 5 (Maintenance Director) on 02/07/23. They acknowledged the findings.

C 613

1.  All items listed needing cleaning and repairs will be addressed by the MD, with utiolization of housekeepers and outside vendors to complete the task.

2.  *Dining room chairs with stains will be cleaned.

*  Arm chairs with splatters will be cleaned.  Arm chairs with tears and exposed stuffing will be removed.

*The cupboards, drawers, and walls in the activity room have been cleaned. 2/10/23

* TThe inside area of the drink station in the dining room has been cleaned, prepped, and repainted.

* The cracks and seams in the main laundry room flooring will be repaired per industry standard.

* Scrapes, dings and deep gouges in doors, in door frames, and nearby walls, will be repaired and painted for all listed locations.

*Carpets will continue to be cleaned with the carpet extrator, with attempts to remove all stains.  Many stains are permanent and we plan torequest an extension as we move forward with replacing the carpet with a flooring upgrade to the facility.  A plan will be developed to replace the carpets in apts. 105,201,206,220.  This will be part of the requested extension.

*MD will repair the hole in the wall in apt. 216, as well as the damaged door frame.  The toilet has been cleaned. 2/9/23

*Apt. 220 will be an ongoing daily repair project for repairing all damages caused by the residents' use of a motorized chair in the apt.  Damage occurs daily, and will be repaired as they occur.

*The countertop in the whirlpool room will be repaired and all chips/dings/scrapes in the wood around the whirlpool will be repaired.

*The two wood benches in the courtyard area have been removed.  2/8/23

*Siding above the dining room doors will be repaired.  Bids have been taken and will be repaired weather permitting, asap. but an extension will be requested to ensur completion.

*The mesh dryer vent box, above the activities room window has been cleaned and will continue to be monitored and cleaned per the TELs maintenance schedule or as needed.

*All dirty cushions, rags, the broken table, h-vac filters, in both areas around the patio have been removed.  2/17/23

3. All areas needing correction will be monitored on a daily basis utilizing the First Impressions program of Prestige.  First Impressions walk throughs occur daily with the CRD, MD, and ED.  The TEL's system for maintemance of the facility , will also be utilized, and the time schedules pre different mantenance tasks will be used and followed.  These times vary based onthe task, (daily, weekly, bi-weekly, monthly).

4.  The CRD, MD, and ED will all be responsible for ensuring that all corrections are made and maintained.

Note:  The ED will be speaking with Prestigecare management about the necessary upgrade for flooring, furniture, and general refurbishment of the facility.  Thus, an extension will be requested for the mentioned items that would be corrected by a facility refurbish and upgrade.

C 999

C 260  This technical item has been corrected.  The resident's care plan was updated to correctly indentify the proper times for using a gate belt with this resident.  The wording in the care plan was changed and is now reflective of the proper procedure for the resident. 2/10/23

C280  An assessment was made to determing the ability of resident 205's ability to safely operate her motorized chair.  A note was sent to her doctor and her family, requesting that a different style of motorized chair be provided.  The RN and ED will be following through with thes request with concerns for the resident's safety and the safety of others.

C 295  A strict reminder was given to all staff at the all staff meeting on 3/23/23, concerning the proper wearing of face coverings.  Staff are being verbally reminded at shift change, and throughout their shift to keep their mask up and properly in place.  All administrative staff are reminded daily in Stand up meeting, and are expected to set an example for all staff and residents, and are to remind staff on an ongoing basis for proper mask wearing.