The findings of the re-licensure survey, conducted 10/19/21 through 10/20/21, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 10/20/21, conducted 01/25/22, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 re-visit, to the re-licensure survey of 10/20/21, conducted 04/11/22, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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

1. On 10/19/21 at 10:25 am the following was observed in the kitchenette in the Memory Care Unit:

* Drawers and cabinet shelves had food particles and crumbs;

* Uncovered plates of food on the stove top and in the microwave;

* Refrigerator had uncovered container of yogurt, unlabeled and undated container of food, and a undated plate of food;

* Container of butter on the counter with crumbs and debris in the butter;

* Open container of petroleum jelly in a drawer with individually packaged saltines; and

* Dish sanitizer not reaching the required temperature and had indicator light noting "Add Sanitizer".

The kitchenette was toured with Staff 2 (Memory Care Administrator). She acknowledged the findings and discontinued the use of the dish sanitizer.

2. On 10/19/21 at 11:15 am the following was observed in the main kitchen:

Spills, splatters, and debris noted on:

* Lower shelving used for storage of utensils and cookware;

* Hand washing sinks;

* Can opener blade;

* Meat slicer;

* Large stand mixer; and

* Floor of the walk in freezer and refrigerator.

Open food items were observed in the dry storage area. Scoops were noted in the large bins of food with the handles in the food.

The dish machine was noted to be high temperature sanitation machine with a data plate indicating 150 degrees F was required for the wash cycle and 180 degrees F for 10 seconds was required for the rinse cycle.

The dish machine was observed to reach 148 degrees F for the wash cycle and 180 degrees F for the rinse cycle, for approximately three seconds.

The dish racks were stored directly on the floor.

The areas needing cleaning and repair were discussed with Staff 1 (Campus Administrator) on 10/19/21. She acknowledged the findings and indicated maintenance of the dish machine had been arranged.

1. Administator created a task sheet for Noc shift for weekly kitchen cleaning. Task sheets includes the following items, checking open date stickers, any open uncovered items must be discarded, cleaning of drawers, cabinets and shelves of all food and crumbs. non food items will be removed from kitchen. Maintanence had eco lab come in and  maintenece for the dish sanitizer on 10/26/21. Temperture log has been added to daily day shift task sheet. 2. Inservice was done on 10/26/21 3. MC Administrator will monitor daily through observastion compliance to this requirement and report at the QA meeting. 4. Campus Administrator will be responsible to see that the Memory care Adminitrator is monitoring this on a weekly bases.   

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 the delivery of services, for 2 of 3 sampled residents (#s 1 and 3), whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2020 with diagnoses including dementia.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 09/09/21 service plan and 07/01/21 through 10/18/21 facility Observation notes were reviewed.

The resident's current service plan was not reflective and did not include clear instruction for staff in the following areas:

* The use of a personal alarm;

* The use of a fall mat at bedside;

* The use of a side rail; and

* The need for nectar thick liquids.

2. Resident 3 was admitted to the facility in 01/2018 with diagnoses including dementia.

Observations of the resident and interviews with staff were conducted throughout the survey. The resident's 07/21/21 service plan and 07/03/21 through 10/14/21 facility Observation notes were reviewed.

Resident 3's service plan directed the use of oxygen for shortness of breath. No oxygen was available for Resident 3. In interviews, staff reported Resident 3 no longer used or needed oxygen.

The need to ensure service plans were reflective of the resident's current health status and provided clear instruction to staff was discussed with Staff 1 (Campus Administrator), Staff 2 (Memory Care Administrator), and Staff 3 (LPN) on 10/20/21. They acknowledged the findings.

1. Resident 1 care plan was updated on 10/20/21to refect the current care that the team is providing.The LPN updated the use of personal alarm, fall mat at bedside, the need for nectar thick liquids and side rail has been removed from service plan as she is no longer using this. It was printed and reviewed by team. Resident 3 use of oxygen is no longer needed, team has repeatly sent out fax to Physician to have this order discontinued off of her care plan. We have not been successful in receiving this discontinue order but will continue to send fax out to physicain until received. 2. Administration will focus on individualizing care plans in order to provide residnet centered care for each resident.  

3.When assesments are due the LPN/RN will update current service plan to reflect current cares and MC Administartor will go through care plans before care team reads them, every 30, 60, 90 days.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short term changes of condition were evaluated, resident-specific instructions or interventions were developed, the condition was monitored weekly until resolved, and residents were monitored per their evaluated needs for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition.  Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 11/2020 with diagnoses including dementia.

Observations of the resident, interviews with staff, and review of the resident's 09/09/21 service plan, 07/01/21 through 10/18/21 facility Observation notes, and physician communications were completed.

The resident experienced the following short-term changes without evaluation of the changes, development of interventions, and documented monitoring at least weekly until resolution:

* Loss of a tooth on 7/20/21; and

* Falls on 8/3/21, 8/7/21, and 8/21/21 resulting in injuries.

The need to ensure short-term changes of condition were evaluated, had documentation to reflect monitoring to resolution at least weekly, and provided clear, resident-specific directions to staff was discussed with Staff 1 (Campus Administrator), Staff 2 (Memory Care Administrator) and Staff 3 (LPN) on 10/20/21. They acknowledged the findings.

2. Resident 3 was admitted to the facility in 01/2019 with diagnoses including dementia.

Observations of the resident, interviews with staff, review of the resident's 07/21/21 evaluation and service plan, and 07/03/21 through 10/14/21 facility Observation notes were completed.

Resident 3 was noted to have a "long history of constipation" on his/her 7/21/21 evaluation.

A 10/14/21 progress note indicated:

"Care staff reported that [Resident 3] not feeling well. When I asked resident what was going on [s/he] reported that [his/her] stomach was cramping. LPN palpated [his/her] stomach and [his/her] right lower quadrant is distended and painful. When checking to see if [s/he] had a BM (bowel movement) recently, LPN found that this is the 7th day without having a bowel movement..."

In an interview with Staff 2 (Memory Care Administrator) on 10/20/21, she reported Resident 3 did have bowel movement on 10/15/21 and 10/18/21. Staff 3 (LPN) stated the BMs had not been documented.

Staff 3 acknowledged there was no evidence Resident 3 had been monitored for constipation per his/her evaluated needs.

The need to ensure residents were monitored per their evaluated needs was discussed with Staff 1 (Campus Administrator), Staff 2 and Staff 3 on 10/20/21. The staff acknowledged the findings.

1.Any changes will be documented to reflect the current care by ISP/Alert Charting with interventions and monitored weekly until resolved with clear resident specific directions to the team. Bowel care was set up in our system on 10/20/2021. 2. Staff training will be done on 11/05/2021 for new bowel care instructions. 2. New daily task sheet was created to check bowel care daily. 3. MC Administrator created new audit binders to be done on a weekly basis for Alert charting/interventions, bowel care will be audited twice weekly on Monday's and Thursday's. 4. MC Administrator will make sure that the corrections are completed and monitored weekly and twice a week for bowel care.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 1 sampled resident (# 3) who had documented medication refusals. Findings include, but are not limited to:

Resident 3's 07/13/21 through 10/14/21 facility Observation notes and current physician orders were reviewed. The records showed multiple medication refusals.

There was no documented evidence the facility notified the physician/practitioner each time the resident refused to consent to orders.  

On 10/20/21, the need to ensure the facility notified physicians/practitioners of medication refusals was discussed with Staff 1 (Campus Administrator), Staff 2 (Memory Care Administrator) and Staff 4 (RCC). They acknowledged the findings.

1.Updated parameters sent out to physician to update when they want to be informed of a missed or med refusal by resident. Pysicain Orders sent out for update on 11/1/21.

2. Team members will fax out physician when there is a missed or refused medication per physicians signed orders. Inservice done and signed on 10/26/21.

3. Rcc will conduct weekly audits on med refusals.

4. Mc Administartor will follow up with RCC weekly on these audits.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 8 and 9) had documented evidence of completion of First Aid certification and training in abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 10/19/21 and revealed Staff 7 (CG), Staff 8 (MA), and Staff 9 (CG), hired 08/03/21, 08/13/21, and 09/05/21 respectively, lacked documented evidence they had completed First Aid certification and abdominal thrust training within 30 days of hire.

The need for staff to complete all required training in the specified time frames was discussed with Staff 1 (Campus Administrator), Staff 2 (Memory Care Administrator), and Staff 4 (RCC) on 10/19/21 and 10/20/21. They acknowledged the findings.

1.Staff training records reviewed by RCC, Campus Administrator and MC Administrator and team members who did not have first aid and abdominal thrust training were pulled off the floor until completed. Proper certified first aid training link to American Health Academy to get certified first aid training has been added to orientation new hire paper work.

2. Prior to team members working on the floor they will finish there pre service dementia training in orientation.Team members will be given 30 days from hire date to finish there certified first aid training and abdominal thrust. 3. Pre service dementia training will be evaluated day of orientation and the abdominal thrust and certified first aid will be evaluated within 30 days of hire.

4. RCC and MC Administartor will be responsible for monitoring and completion of training.1

Based on interview and record review, 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 Z155.

1)6-hour Pre-dementia training: The facility has put into place a new HR structure to help ensure that all Memory care staff are properly trained and complete the 6-hour pre-dementia training before training in the facility with residents.

a.Upon a new hire, the new hire is given all online links to complete

i.6-hour pre-dementia training through Oregon Care partners

ii.First aid

iii.Food handlers' card

b.These are then presented to the HR department or Administrator to file in their chart

c.The new employee will then be scheduled to train with the staff on the floor

2)Completion of training materials for working with the residents

a.Employee will carry their task completion sign of sheet with them throughout training

b.The staff that is training the new employee will sign off daily until the new employee has completed this form and is deemed competent in these tasks.

3)16 hours of annual dementia care training

a.The Administrator or RCC will assign 16 hours of additional dementia training and track this with printed certificates from the staff members throughout the year, through Oregon Care Partners or other assigned dementia training materials.

b.The Administrator or RCC will notify staff members in a timely manner that their training is coming up.  

c.If the employee goes past their due date, that employee will be pulled from direct care staff duties until the training has been completed.

The training and task materials will be evaluated 30 days after the employee has started by the Administrator or the RCC. The Administrator or RCC will meet with the employee to review their competency and their sign off task sheet.

The 16-hour annual dementia care training will be evaluated every quarter by the Administrator or the RCC. The employee will be contacted when their due dates are approaching and assign them their trainings.

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

During a walk-through of the facility on 10/19/21, exit doors were found to have no working audible alarm or system in place to alert staff when a resident exited the building.

The need to ensure all exit doors were equipped with an acceptable system to alert staff when a resident exited was discussed with Staff 1 (Memory Care Administrator) on 10/19/21. She acknowledged the findings.

1. An alarm system will be placed on exit doors going into patio area in memory care approximatley November 4th based off delivery time. Base of alarm system placed at care satff center so when alarm goes off team members are aware that residents are outside. Inservice will be done on November 4th with directions and usage of alarm system.2. Alarm system will remain on door at all times. 3. MC Administartor will monitor that door alarm is in working condition and on at all times weekly.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240, C372 and C555.

Refer to C240 and C372    

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 8 and 9) had completed all required pre-service dementia training prior to working with residents, and 2 of 2 long term staff (#s 10 and 11) completed 16 hours of annual training. Findings include, but are not limited to:

Staff training records were reviewed on 10/19/21.

1. Staff 8 (CG), hired 08/13/21, and Staff 9 (MA), hired 09/05/21, did not complete the required pre-service dementia training prior to working with residents.

2. There was no documented evidence Staff 10 (CG) and Staff 11 (CG), hired 12/20/19 and 10/08/19 respectively, completed 16 hours of in-service training annually during 2020.

The facility's failure to ensure staff completed all required training was discussed with Staff 1 (Campus Administrator), Staff 2 (Memory Care Administrator) and Staff 4 (RCC) on 10/19/21 and 10/20/21. They acknowledged the findings.

1.Staff training records reviewed by RCC, Campus Administrator and MC Administrator and team members who did not have pre service dementia training were pulled off the floor until completed.

2. Prior to team members working on the floor they will finish there pre service dementia training in orientation. 3. Pre service dementia training will be evaluated day of orientation and completed before being scheduled on the floor for training, Dementia competence training will be done monthly and long term ongoing in service 16 hours total with the 6 hour Dementia included.

4. RCC and MC Administartor will be responsible for monitoring and completion of training.       

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 14 and 15) had completed all required pre-service orientation and dementia training prior to working with residents. This is a repeat citation.  Findings include, but are not limited to:

Staff training records were reviewed on 01/25/22.

Staff 14 (MT), hired 12/15/21, and Staff 5 (MT), hired 12/26/21, did not complete the required pre-service orientation and dementia training prior to working with residents.

The facility's failure to ensure staff completed all required training was discussed with Staff 2 (Memory Care Administrator) and Staff 13 (RCC) on 01/25/22. They acknowledged the findings.

1)6-hour Pre-dementia training: The facility has put into place a new HR structure to help ensure that all Memory care staff are properly trained and complete the 6-hour pre-dementia training before training in the facility with residents.

a.Upon a new hire, the new hire is given all online links to complete

i.6-hour pre-dementia training through Oregon Care partners

ii.First aid

iii.Food handlers' card

b.These are then presented to the HR department or Administrator to file in their chart

c.The new employee will then be scheduled to train with the staff on the floor

2)Completion of training materials for working with the residents

a.Employee will carry their task completion sign of sheet with them throughout training

b.The staff that is training the new employee will sign off daily until the new employee has completed this form and is deemed competent in these tasks.

3)16 hours of annual dementia care training

a.The Administrator or RCC will assign 16 hours of additional dementia training and track this with printed certificates from the staff members throughout the year, through Oregon Care Partners or other assigned dementia training materials.

b.The Administrator or RCC will notify staff members in a timely manner that their training is coming up.  

c.If the employee goes past their due date, that employee will be pulled from direct care staff duties until the training has been completed.

The training and task materials will be evaluated 30 days after the employee has started by the Administrator or the RCC. The Administrator or RCC will meet with the employee to review their competency and their sign off task sheet.

The 16-hour annual dementia care training will be evaluated every quarter by the Administrator or the RCC. The employee will be contacted when their due dates are approaching and assign them their trainings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C260, C270 and C305.

Refer to C260, C270 and C305