The findings of the re-licensure survey, conducted 10/24/22 through 10/27/22, 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 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 revisit to the re-licensure survey of 10/27/22, conducted 03/21/23 through 03/22/23 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 observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

A survey of the first-floor kitchen was completed by Nursing Facility surveyors on 07/01/22.

The second-floor kitchen was toured on 10/24/22 and showed the following:

* Brown build-up on floor at the baseboard juncture throughout kitchen;

* Dust build-up on kitchen fans, including fan above clean dishes exiting ware washer;

* Black debris on full length of windowsill;

* Gouges on walls in multiple areas exposing drywall, creating an uncleanable surface;

* Paper signs throughout kitchen, creating an uncleanable surface; and

* Garbage cans throughout kitchen did not have lids.

These findings were reviewed with Staff 9 (Kitchen Manager) and Staff 10 (Dining and Food Services Director) on 10/25/22 and with Staff 1 (Administrator) on 10/26/22. They acknowledged the findings.

All areas in the kitchen and pantry observed to be unclean during survey process have been cleaned.  Garbage cans with lids have been ordered and papers have been taken down and replaced with papers in plastic wipeable sleeves.  

Aprons have been purchased and staff have been retrained on proper hand hygeine.   

Daily cleaning assignments/tasks have been delegated to staff.  Weekly deep clean days with additional heavy duty cleaning tasks have been implemented.   

Windowsills, fans, floor/baseboard juncture, and walls are all on cleaning schedule and have been delegated to staff. Director of Dining servies or an appointed staff will walk kitchen daily to assure ongoing compliance and cleaning will remain intact.  

Weekly audit of all items listed above will be performed by the Director of Dining servies or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 2 sampled resident (# 1). Findings include, but are not limited to:

Resident 1 was admitted to the facility in 06/2021 with diagnoses including Alzheimer's disease and depression.

Observations of the resident, interviews with staff and the resident, and review of the service plan, dated 09/14/22, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:

* Nutritional preferences (likes/dislikes);

* Denture care;

* Transfer assist, including instructions for one versus two person assist;

* Wheelchair mobility;

* Evacuation assistance needed; and

* Glasses.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator) and Staff 5 (LPN) on 10/27/22. They acknowledged the findings.

Resident 1's Service Plan has been updated to include missing fields as identified in survey. Specifically, nutritional preferences, denture care, transfer assist, wheelchair mobility, evacuation assistance and glasses.  

Person's responsible for Service Plans have been retrained on the required componants of the service plan and Service Plan schedule - initial, 30 days, with significant change of condition and quarterly.

A sample of Service Plans will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs.

A monthly evaluation report to be generated to determine due dates and ensure compliance.  

The RCCs and Administrator are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure the delegation and supervision of special tasks of nursing care were completed in accordance with the Oregon State Board of Nursing (OSBN) Administrative Rules for 1 of 1 sampled resident (#3) who received insulin injections by unlicensed staff. Findings include, but are not limited to:

Delegation records for Resident 3, reviewed on 10/27/22, indicated the RN failed to document all required components of delegation in accordance with the OSBN Administrative Rules for Staff 10 (MT), Staff 11 (MT), and Staff 12 (MT) to include:

* Nursing assessment and condition of the client to determine if the client's condition was stable and predictable;

* The rationale for deciding the task of nursing care could be safely delegated to unlicensed persons;

* Frequency the client should be reassessed, including rationale; and

* Re-evaluation of the condition of the resident and skill of the delegated staff within 60 days of initial delegation.

The need to ensure delegation of special tasks of nursing care was documented in accordance with OSBN Administrative Rules was reviewed with Staff 1 (Administrator) and Staff 5 (LPN) on 10/27/22. They acknowledged the findings.

LPNs are the only staff who are currently administering insulin.  

We are working to find an Agency RN for temporary support and Elderwise nurse consulting is supporting us as we work to hire an RN.

Will provide training to incoming RN on proper delegation protocol.

The Administrator and Director of Health Services will review Delegation records weekly.

Based on interview and record review, it was determined the facility failed to ensure physician orders were carried out as prescribed for 2 of 3 sampled residents (#s 3 and 4) whose orders were reviewed. Findings include, but are not limited to:

1. Resident 4 was admitted to the facility in 06/2018.

The resident's 10/02/22 through 10/26/22 TAR was reviewed, as well as current physician orders for Resident 4 and identified the following orders were not being administered as prescribed:

* A signed physician order to apply Triple Antibiotic First Aid Ointment to Resident 4's right nostril three times a day, was not administered on 6 occasions.

On 10/27/22, the need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator). She acknowledged the findings.

2. Resident 3 was admitted to the facility in 03/2022 with diagnoses including diabetes.

The resident's 10/01/22 through 10/26/22 MAR and progress notes, as well as current physician orders, were reviewed and staff were interviewed. The following was identified:

* The resident had an order for Humalog (insulin) 100 units/ml, three times daily before meals, to be administered on a sliding scale. In addition, there were orders to check the resident's blood sugar level if s/he exhibited signs or symptoms of low blood sugar or high blood sugar.  

There were no documented CBG levels for the following dates and times:

- 10/02/22 at 7:30 am and 11:00 am;

- 10/03/22 at 4:30 pm;

- 10/08/22 at 4:30 pm; and

- 10/11/22 at 11:30 am.

* The resident had an order for scheduled Glargine (insulin) 100 units/ml, 35 units to be injected one time per day. On 10/02/22, the injection was not initialed by a MT as having been administered.

In an interview on 10/27/22 Staff 1 (Administrator) and Staff 8 (LPN) were unable to provide any information about whether or not the insulin had been administered.

The need to follow physician orders as prescribed was discussed with Staff 1, Staff 5 (RN Consultant), and Staff 5 on 10/27/22. They acknowledged the findings.

Retrained staff on the importance of completing documentation in the MAR/TAR and administering medications as ordered.

LN or designee will routinely audit MAR/TAR to flag and address missing documentation.  Report of Audits given at monthly QAPI

Director of Health Services, LPN and Administrator will be responsible to see the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 14, 15, and 16) completed all required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents and 2 of 2 long-term staff (#s 7 and 22) completed infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to:

Staff training records were reviewed on 10/25/22 and revealed the following:

1. There was no documented evidence Staff 13 (MT), Staff 14 (MT), Staff 15 (CG), or Staff 16 (CG), hired 08/02/22, 08/30/22, 08/30/22, and 09/19/22, respectively, completed one or more of the following required pre-service orientation elements prior to performing any job duties:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious Disease Prevention;

* Fire safety and emergency procedures; and

* Written job description.

2. There was no documented evidence Staff 13, Staff 14, Staff 15, or Staff 16 completed one or more of the following dementia training topics prior to providing care to residents:

* Techniques for understanding, communicating, and responding to behaviors and reducing the use of antipsychotics;

* Strategies for addressing social needs and engaging them in meaningful activities; and

* Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, and the use of the person-centered approach.

3. There was no documented evidence Staff 7 (Marketing), hired 05/03/22, or Staff 22 (Director of Environmental Services), hired 08/26/02, completed infectious disease prevention training prior to 07/01/22.

The need to ensure training is completed by newly hired and long-term staff within the required time frame was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required trainings and documentation verifying training is in place.

The Staffing Coordinator has been retrained on required pre-service training and documentation needed for new employees.  

Auditing tools are implemented for ongoing monitoring of pre-service training for new employees.

Training records will be audited monthly by the Staffing Coordinator and reported to Administrator.  

The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure 2 of 4 newly hired staff (#s 15 and 16) demonstrated competency in all assigned job duties within 30 days of hire, including first aid and abdominal thrust. Findings include, but are not limited to:

Staff training records were reviewed on 10/25/22 and the following was identified:

1. There was no documented evidence Staff 15 (CG), hired 08/30/22, or Staff 16 (CG), hired 09/19/22, demonstrated competency in the following areas within 30 days of hire.  

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation, and reporting of changes of condition;

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

* General food safety, serving, and sanitation; and

*First Aid/abdominal thrust.

The need to ensure newly hired employees demonstrated competency in all assigned job duties, and completed first aid and abdominal thrust training, within 30 days of hire was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required compentancy trainings and documentation verifying training is in place.

Auditing tools are in place and Staffing Coordinator has been retrained on required compentancy training and documentation needed for new employees.  

The Staffing Coordinator will audit training documents prior to each new employee working independently and give monthly report to administrator.

The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored

Based on interview and record review, it was determined the facility failed to ensure and document 4 of 4 long-term staff (#s 11, 12, 17, and 18) completed 12 hours of annual in-service training, including at least 6 hours related to dementia care. Findings include, but are not limited to:

Staff training records were reviewed on 10/25/22 and revealed the following:

There was no documented evidence Staff 11 (MT), Staff 12 (CG), Staff 17 (CG), or Staff 18 (CG), hired 06/21/19, 12/23/19, 03/11/05, and 07/01/03, respectively, completed at least 12 hours of training related to the provision of care in CBC, with  a minimum of six hours of training on dementia care topics.

The to ensure long-term staff completed the required number of hours of annual in-service training and document the training was discussed with Staff 1 (Administrator) on 10/26/22. She acknowledged the findings.

All Employee files have been audited for compliance with annual on-going training.  All staff identified as dificient in training have since been assigned training and will be monitored until completion.  

Training will be assigned monthly along with our on-going inservices.

The Staffing Coordinator, Administrator and/or designee will audit for compliance monthly.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months and to document all required elements of fire drills required by the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/25/22, and the following was identified:

* There was no documented evidence staff were instructed on fire and life safety on alternate months from fire drills; and

* Fire drill records did not include evidence drills were being conducted on all shifts or alternate escape routes were used during drills.

The need to provide fire and life safety instruction to staff and document all required elements of fire drills as required by the OFC was discussed with Staff 1 (Administrator) and Staff 5 (Operations Director) on 10/26/22. They acknowledged the findings.

Person's responsible for Fire Life safety training and drills has been retrained on fire life safety training and documenatation.  Missing componants in documentation have been added to training materials.

The Facility Ops director has updated the training schedule and training requirements.

Fire Life Safety training records will be reviewed monthly.  

The Facility Operations Director and Adiminstrator will be responsible to see that the corrections are completed and monitored.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. Findings include, but are not limited to:

Fire and life safety records were reviewed on 10/25/22.

There was no documented evidence of 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 as required by the Oregon Fire Code was discussed with Staff 1 (Administrator) on 10/26/22.

Person's responsible for Fire Life safety Resident instruction have been retrained on fire life safety training requirements and documenatation.  Materials for resident instruction have been created.  

The RCCs have audit tool in place to ensure ongoing intruction to residents each quarter.   

The RCCs and Adiminstrator will be responsible to see that the corrections are completed and monitored.