The findings of the re-licensure survey, conducted 05/23/22 through 05/25/22, 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

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 05/25/22, conducted 11/01/22 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure all required postings were displayed in a conspicuous location for residents and visitors and available for inspection at all times. Findings include, but are not limited to:

During a tour of the environment on 08/23/22, there were no postings related to the administrator or designee in charge or the current facility staffing plan.

The findings were reviewed with Staff 1 (Administrator) on 08/23/22. He acknowledged the findings.

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

During a tour of the laundry room on 05/23/22, Staff 7 (MT) reported staff rinsed soiled linens and clothing in the utility sink before laundering.

The laundry room was toured with Staff 1 (Administrator) on 05/23/22 and 05/24/22. He reported the facility did not have a process for disinfecting the sink following each use.  The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure that all incidents of abuse, suspected abuse, and injuries of unknown cause were thoroughly investigated to rule out abuse for 2 of 2 sampled residents (#s 2 and 4) whose facility records were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 02/2022 with diagnoses including cerebral infarction.

Review of the resident's 02/15/22 through 05/23/22 progress notes revealed the resident experienced the following:

* 05/07/22 - Blister on right ankle; and

* 05/19/22 - Wound on left pinky toe.

There was no documented evidence the facility investigated the blister on Resident 4's right ankle after it was discovered on 05/07/22.

Review of an investigation dated 05/18/22, related to the wound on Resident 4's pinky toe, revealed the facility did not rule out abuse and failed to address the following required elements:

* Time and place of the incident;

* Follow-up action, including measures taken to prevent future reoccurrence to the resident; and

* Administrator's review, including signature and date of review.

The need to promptly and thoroughly investigate incidents of abuse, suspected abuse, and injuries of unknown cause was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 02/2021 with diagnoses including cerebral palsy and chronic pain.

The resident's facility record was reviewed, including progress notes dated 02/22/22 through 05/23/22 and an incident report dated 05/23/22, and interviews with staff and the resident were conducted.

On 05/20/22, Resident 2 experienced an unwitnessed fall while transferring from his/her wheelchair to the toilet. An incident report was completed on 05/23/22. The facility investigation of the fall did not include the following elements:

* Time, date, place, and individuals present;

* Description of the event as reported;

* Response of staff at the time of the event, including measures taken to immediately protect the safety of the resident;

* Follow-up action, including measures taken to prevent future reoccurrence to the resident; and

* Administrator's review, including signature and date of review.

The need for a timely and thorough investigation of all incidents of abuse or suspected abuse was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

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

The kitchen was toured on 05/23/22 at 10:55 am, and the following was identified to be in need of cleaning and/or repair:

* A burner knob on the stove was loose and came off easily;

* The paint was chipping off cabinet doors and drawer fronts, exposing bare wood;

* Cabinet door handles and drawer knobs were sticky;

* There was food debris in the small drawer to the right of the stove;

* The paint was wearing off the dry storage shelves, exposing bare wood;

* The floor in front of the dry storage shelves had a build-up of brownish-gray matter; and

* The kitchen door did not close unless it was physically lifted by the doorknob to fit into the door frame.

Staff 5 (Chef) reported he used soap and water, then a disinfectant spray to clean the kitchen countertops/food prep areas and stated they did not have test strips.

Areas needing cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) at 2:30 p.m. on 05/23/22.

The need to use specific cleaning products, such as Quaternary or bleach, along with test strips, to clean kitchen countertops/food prep areas, along with test strips, was discussed with Staff 1 on 05/24/22 at 10:10 a.m. He indicated he would purchase an appropriate chemical the same day.

At 5:05 p.m. on 05/24/22 the tray line was observed, and it was discovered staff were not taking temperatures of the food before it was served. The need to temp food prior to serving was discussed with Staff 1 and Staff 2 (Assistant Administrator) on 05/24/22 at 5:10 pm.

The need to follow the Food Sanitation Rules was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure new move-in evaluations addressed all required elements for 2 of 2 sampled residents (#s 1 and 4) whose facility records were reviewed. Findings include, but are not limited to:

Review of the new move-in evaluations for Resident 1 (admitted 05/2022) and Resident 4 (admitted 02/2022) revealed the facility failed to address multiple required elements.

The need to ensure new move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed in a timely manner for 1 of 1 sampled resident (#4) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2022 with diagnoses including cerebral infarction.

Review of the resident's 02/15/22 through 05/23/22 progress notes, outside provider notes, and RN assessments revealed the following:

02/25/22: Staff progress notes indicated the resident had a "pressure ulcer...small wound...open";

02/28/22: The home health PT noted the resident had a bandage on his/her sacrum;

03/01/22: The home health RN assessed the wound as a Stage 2 pressure ulcer;

03/04/22: A progress not written by the RN indicated she did not assess the resident's sacrum that day, as s/he had gone to the emergency department for an unrelated condition;  

02/25/22 - 03/11/22: There were multiple staff entries in the progress notes related to "pressure ulcer monitoring"; and

03/11/22: The facility RN completed an assessment of the wound.

During an interview with Staff 2 (Assistant Administrator) and Staff 4 (RN) on 05/24/22, Staff 4 reported she could only complete an assessment if she knew about the condition.

The need to ensure an RN significant change of condition assessment was completed in a timely manner was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Manager), and Staff 4. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order for 1 of 1 sampled resident (#4) who had documented refusals of medication. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2022 with diagnoses including cerebral infarction.

Review of the resident's current physician orders and 05/01/22 through 05/23/22 MAR revealed the resident had refused administration of a nicotine patch on multiple occasions, for which there was no notification of the physician.

The need to ensure the physician or other practitioner was notified when a resident refused to consent to a medication or treatment order was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 02/2022 with diagnoses including cerebral infarction.

Review of the resident's 05/01/22 through 05/23/22 MAR and current physician orders revealed the resident had PRN orders for both acetaminophen and hydrocodone for pain. There were no resident-specific parameters on the MAR which instructed unlicensed staff which medication to administer first.

The need to ensure MARs were accurate and included medication-specific parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included medication-specific parameters for PRN medications for 2 of 2 sampled residents (#s 2 and 4) whose MARs were reviewed. Findings include, but are not limited to:

1. Resident 2's 05/01/22 through 05/23/22 MAR was reviewed and revealed multiple PRN pain and asthma medications lacked resident-specific parameters, and there were duplicate orders for Mylanta (an antacid) and Pepto Bismal (an antinausea medication).

The need to ensure MARs were accurate and included clear parameters for PRN medications was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications had written, resident-specific parameters and non-pharmaceutical interventions to attempt prior to administering the medication for 1 of 1 sampled resident (#3) who was prescribed and used PRN psychotropic medication. Findings include, but are not limited to:

Resident 3 was admitted to hospice services in 01/2022 with diagnoses including congestive heart failure.

Hospice prescribed lorazepam 0.5 mg every four hours as needed for anxiety or shortness of breath. The MAR lacked instruction related to non-pharmacological interventions for staff to attempt prior to administration of the medication and failed to identify how the resident's anxiety was displayed.

Resident 3 was administered PRN lorazepam on 05/08/22, 05/11/22, and 05/15/22. There was no documentation which indicated why the medication had been administered or that non-pharmacological interventions had been attempted without success prior to administration.

There was no documented evidence hospice had instructed staff to administer the PRN psychotropic medication without attempting non-pharmacological interventions first.

The need to ensure the MAR included a description of how the resident exhibited anxiety and non-pharmacological interventions to attempt prior to administering the PRN psychotropic medication was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/23/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure supportive devices with potentially restraining qualities were assessed, including a thorough review by an RN, PT or OT prior to use, instruction to caregivers on the correct use and precautions of the device were provided, and use of the device was included in the resident's service plan for 1 of 1 sampled resident (#4) who used a tilt-in-space wheelchair. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 02/2022 with diagnoses including cerebral infarction.

A tilt-in-space wheelchair was observed in the resident's room on 05/24/22. The controls for adjusting the position of the chair were located behind the seat where the resident would be unable to reach them. During an interview with the resident on 05/25/22, s/he confirmed that s/he must ask staff for assistance to adjust the chair.

The need to ensure supportive devices with potentially restraining qualities were assessed, including a thorough review by an RN, PT or OT prior to use, instruction to caregivers on the correct use and precautions of the device were provided, and use of the device included in the resident's service plan was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 8 and 9) completed pre-service orientation and dementia training in the required timeframe. Findings include, but are not limited to:

Staff training records were reviewed on 05/24/22 and revealed the following:

1. Staff 8 (CG), hired 03/03/22, completed pre-service dementia training on 05/25/22, which was after she began providing care to residents.

2. Staff 9 (Activity Director/Chef), hired 04/20/22, failed to sign her job description prior to performing any job duties.

The need to ensure all pre-service orientation and dementia training was completed in the specific timeframes was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 3 and 6) completed a minimum of six hours of dementia care in-service training annually. Findings include, but are not limited to:

Staff training records were reviewed on 05/24/22.

There was no documented evidence Staff 3 (Manager), hired 01/23/19, and Staff 6 (CG), hired 03/16/12, completed a minimum of six hours of dementia care annually.

The need to complete all required annual training in a timely manner was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3, and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure life safety instruction was provided to staff on alternate months as required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 05/25/22.

There was no documented evidence the facility provided fire and life safety training instruction to staff on alternating months from fire drills.

The need to provide staff fire and life safety training on alternate months was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

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

Fire and life safety records were reviewed on 05/25/22 and revealed a lack of documented evidence related to the following required elements:

* Instruction to residents on fire and life safety procedures within 24 hours of admission.

* A written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire.

The need to ensure residents were provided instruction per the Oregon Fire Code was discussed with Staff 1 (Administrator), Staff 2 (Assistant Administrator), Staff 3 (Manager), and Staff 4 (RN) on 05/25/22. They acknowledged the findings.

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

During a tour of the courtyard on 05/23/22, the following tripping hazards were observed:

* There were two cracks in the concrete patio which created an uneven surface; and

* Multiple drop-offs of two to three inches were noted along edges of the patio.

The need to ensure the environment was maintained in good repair to prevent potential tripping hazards was discussed with Staff 1 (Administrator ) on 05/23/22. He acknowledged the findings.

Based on observation and  interview, it was determined the facility failed to ensure the interior of the building was maintained clean and in good repair. Findings include, but are not limited to:

During a tour of the environment on 05/23/22, the following were identified:

* There were multiple chips in the laminate flooring;

* There were raised transition moldings in the flooring which presented a tripping hazard for residents; and

* There were stains on multiple dining room chairs.

The findings were reviewed with Staff 1 (Administrator) on 05/23/22 and 05/25/22. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure washing machines had a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant was used. Findings include, but are not limited to:

A survey of the laundry room on 05/23/22 revealed the facility used residential washing machines which did not indicate the rinse temperature and laundry detergent which lacked a chemical disinfectant.

The environment was toured with Staff 1 (Administrator) on 05/23/22. He acknowledged the findings.