The findings of the re-licensure survey conducted 01/31/22 through 02/02/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care, 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  revisit to the re-licensure survey of 01/31/22, conducted on 04/15/22, 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 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 4 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to:

Resident 4 was admitted to the facility in 01/2019. Resident 4's MAR and physician orders, reviewed from 01/01/22 through 01/31/22, identified the following:

Resident 4 had an order for Elmron 100 mg 1 capsule three times a day before meals for radiation cystitis (inflammation of the bladder caused by radiation). According to the MAR, staff gave the second dose at 2:00 pm and the third dose at 8:00 pm not before meals as ordered.

In interviews on 02/02/22, the surveyor, Staff 2 (RN Consultant) and Staff 5 (CG/MT) reviewed the MARs and orders. They acknowledged Elmron had not been administered as ordered. Staff 5 stated she would change the administration times for the medication.

The need to ensure orders were carried out as prescribed was reviewed with Staff 1 (Administrator) and Staff 2 (Office Support) on 02/02/22. They acknowledged the findings.

Med-Aids to be retrained on policies regarding meds being administered as ordered. To ensure meds are administered correctly the Med-Aid will review the order to ensure all needed informaiton is available, write the order in the MAR, review for the med name, dosage, route, and times to ensure written correctly, initial the bottom right corner of the order, and place the new order in the 2nd check file folder hanging on the wall behind the RCM's desk.  

The Med-Aid coming on duty the following shift will do a 2nd check on the orders in the 2nd check file folder. They will look at the doctor's order and compare it to the MAR to ensure it has been entered correctly.

The new order will then be placed in the file folder labeled LN/Admin 3rd check. The LN will do 3rd checks on new orders the next time they are in the building. The Admin. can check new orders if the LN will not be in for a few days.

The Admin. will monitor the 3rd check file weekly to ensure the orders have been checked for accuracy 3 times.    

When new orders are filed in the resident charts, the person filing will watch for 3 initials on each order.

The Admin. will randomly pull 3 files quarterly to ensure orders have been checked 3 times.  

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff (#s 7, 10 and 12) had completed all required areas of training within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 02/02/22 at 9:42 AM revealed:

1. There was no documented evidence Staff 7 (MA), hired 10/15/21, had demonstrated competency in all required areas and within 30 days of hire including:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting of changes of condition;

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

* General food safety, serving and sanitation.

Additionally, there was no documented evidence Staff 7 had completed First Aid certification and abdominal thrust training.

2. There was no documented evidence Staff 10 (CG), hired 12/08/21, had completed First Aid certification and abdominal thrust training within 30 days of hire.

3. There was no documented evidence Staff 12 (CG), hired 10/27/21, had completed First Aid certification within 30 days of hire.

The need to document demonstrated competency in job duties and complete First Aid certification and abdominal training within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 3 (Office Support) on 02/02/22. They acknowledged the lack of documented evidence the required training had been provided.

A new system for tracking and documenting training is being created to ensure all directy care staff have completed ALL required training within 30 days of hire, and shown competency in all duties assigned, within 30 days of hire.

This system will include a quick reference or overview of each employee's training in the fronty of their employee file where it can be easily accessed and double checked by both HR and administration.

Additionally policies/procedures related to hiring/training will be created and/or updated as needed to comply in full with OAR 411-054-0700.

All new hire training documentation will be double checked by HR weekly for the first 30 days, and again by both HR and Administrator at the end of 30 days.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include but are not limited to:

The facility grounds were toured on 01/31/22 and the following was observed:

* The exterior pathways throughout resident walkways were uneven and cracked, with concrete drop-offs greater than two inches in multiple areas. This created a potential tripping and fall hazard for residents;

* A concrete pathway between buildings had areas covered with leaves and yard debris creating slippery surfaces to walk;

* Accumulation of yard debris around the building;

* A damaged window screen on the ground; and

* Scattered pieces of lumber along the grounds of the courtyard.

The building exterior was toured with Staff 1 (Administrator) on 02/02/22. She acknowledged the findings.

We have an appointment with a concrete repair company on 2/17/22 to determine what needs to be done to even out and repair the uneven concrete.

Maintenance will fill the concrete drop offs along the sidewalks and clean any pathways and areas of leaves and yard debris.

Any items, ie: screen, lumber will be picked up and put away along the grounds in the courtyard.

Maintenance will check the grounds weekly for any needs and the owner will check the grounds monthly to ensure items are picked up.

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 01/31/22 through 02/02/22 showed the following areas were in need of cleaning and/or repair:

* Multiple walls, doors and door frames throughout the facility were dinged, chipped, gouged, scraped and/or had black streaks;

* Several pieces of furniture throughout the facility had worn areas and stains;

* Carpet throughout the facility and resident rooms had multiple stains;

* Multiple windowsills had buildup of dirt and debris;

* Ceiling vents throughout the facility and bathrooms had buildup of dust and debris;

* Hallway overhead light was missing a cover;

* Multiple baseboard heaters were in need of repair including the baseboard heater in room 20 was pulling away from the wall; and

* The cat litter box in the TV room needed routine cleaning.

The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 3 (Maintenance) on 02/02/22. They acknowledged the findings.

The walls, doors and door frames will be repaired by the maintenance department.

Walls, doors and door frames will be checked for any dings, chips, gouges, scrapes or black streaks monthy and repaired by maintenance.

Furniture with stains or worn areas will be replaced by the owners.

Carpets in the commons areas and resident rooms with stains will be shampooed by mainitenance and/or housekeeping.

Window sills will be checked/cleaned by housekeeping monthly in the resident rooms and by the HS universal workers in the commons areas.

Ceiling vents will be cleaned of dust and debris by maintenance, and hallway light cover replaced. These will be checked monthly by maintenance addressed, prn.

Baseboard heaters are in the process of being replaced and will be checked quarterly by maintenance.

The cat box has been cleaned and will be cleaned nightly by the Universal Worker. The housekeeper will check the cat box weekly to enusure cleaning is happening.

Housekeepers, managers, universal workers and carestaff will be asked to report any stained carpets, dirty windowsills, vents,walls, gouged walls/doors, dirty/worn furniture, scaped/dinged woodwork, missing light covers, damaged base boards, to Administration or the owners.

A check off list will be created for Maintenance to check on all above items monthly and tuned into Administration. Administration will check/verify for accuracy the Maintenance Check off List quarterly.