The findings of the re-licensure survey conducted 05/08/23 through 05/11/23 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, 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 re-visit to the re-licensure survey of 05/11/23, conducted 08/03/23, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

2. Resident 6 was admitted to the facility in February 2017 and was identified to utilize a urinary catheter.

On 05/09/23 at 1:20 pm, Resident 6 was observed seated in a low recliner in his/her room, dressed in a t-shirt, and incontinent product with the tubing of the catheter on the floor. The night bag was hung on a wheelchair next to the resident.

Staff 17 (CG) was notified Resident 6 needed assistance. The resident was assisted to get dressed for the day and the catheter was changed to a leg bag.

On 05/10/23 at 9:15 am, Resident 6 was observed seated in a low recliner in his/her room with the tubing and catheter night bag on the floor.

Staff 2 (RN) observed the resident and the catheter bag on the floor. She acknowledged the catheter was improperly managed and posed an infection control risk.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control and to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in September 2019 with diagnoses including dementia.

On 05/09/23 at 9:40 am, the surveyor obtained permission and observed Staff 2 (RCC) and Staff 15 (CG) provide incontinent care for Resident 2. During the observation, Staff 15 failed to change gloves after removing a soiled incontinent product and wiping feces from Resident 2's perineum. Staff 2 (RCC) and Staff 15 (RCC) were observed placing a soiled incontinent product and soiled wipes on the floor of Resident 2's room.

The need for reasonable precautions to be exercised against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 (ED) on 05/11/23 at 2:30 pm. The findings were acknowledged.

C160: Reasonable Precautions-Infection Control

Community care staff will be retrained on infection control policies at all-staff meeting and on an individual bases by compliance date of July 10th, 2023 to prevent soiled items contaminating non-designated surfaces. Staff performing resident care will be given uniforms with additional pockets or aprons to allow them to carry trash bags for proper handling. ED, RN, and Infection Control Specialist (currently the RCC) to monitor on an ongoing basis, and continued infection control education through Relias courses.

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

Observations of the facility's lunch service on 05/10/23 revealed:

* Staff were observed to not change gloves between tasks during meal service while touching ready to eat food;

* Staff did not practice hand hygiene between dirty and clean tasks, i.e. bussing dirty dishes and serving beverages and food; and

* Caregiving staff assisting with meal service and delivery did not don aprons.

The food handling and infection control observations were reviewed with Staff 1 (ED) on 5/10/23. She acknowledged the findings.

C160, Z142: Reasonable Precautions- Infection Control

Community care staff will be retrained on the importance of proper catheter management with the focus of infection control by compliance date of July 10th, 2023. Care staff will be instructed by House RN and Infection Control Specialist (RCC) with oversight by the Executive Director to monitor for completion. Following these trainings will be recurring Relias courses and in-services at caregiver staff meetings.

Based on observation and interview, 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 C 160 and C 240.

C240: Food and Sanitation Rules

Staff who directly serve food will be instructed to don aprons while serving to community residents and to follow proper hand hygiene techniques. Servers should be following requirements by July 10th, 2023 by the latest. ED, RCC, and Executive Chef will monitor staff routinely to ensure proper meal etiquette is being performed as well as additional training though Relias and staff meetings annually and as needed.

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 newly hired staff demonstrated and documented competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 05/09/23 and 05/10/23. The following was identified:

There was no documented evidence Staff 19 (CG) hired 09/26/22, demonstrated competency in the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

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

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

* General food safety, serving and sanitation.

Staff 1 (ED), in an interview on 05/10/23, reported she had no further documentation related to the 30 day competency completion for the staff reviewed.

The need to ensure all new hires demonstrated competency in job duties within 30 days of hire was discussed with Staff 1 (ED) on 05/10/23. She acknowledged the findings.

Z155: Staff Training Requirements

Current community teammates will have their employee files reviewed to ensure they have completed a 30-day competency checklist fitting for their job title. All newly hired staff are to complete this within their first month of employment. ED, RCC, and Business Office Manager are to ensure all documentation complies with OAR's by July 10th, 2023. Following the 30-day competency checklist, all staff are to complete routine in-service education at both staff meetings and through Relias courses.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 4 of 6 sampled residents (#s 1, 2, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1, 2, 4 and 5's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

Observations on 05/08/23 and 05/09/23 showed Resident 1, 2 and 5 in their rooms without any staff interaction.

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities.

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (ED), Staff 2 (Health Services Director) and Staff 4 (Activities Director) on 05/11/23. They acknowledged the findings.

Z164: Individualized Activity Plans

Mt Bachelor's Executive Director, Lifestyle Director, Resident Care Coordinator, and House RN are to meet and review resident's #1, 2, 4 and 5 service plans. Service Plans are to have a detailed explanation on this community's understanding of residents past and current interests, current abilities and skills, emotional/social needs, physical abilities/limitations and any adaptions needed for resident participation, and how activities may be utilized for behavioral interventions. The listed residents should have updated activity-focused service plans created by compliance date of July 10th, 2023. Following compliance date, ED, RN, RCC, and Lifestyle Director will discuss all resident service plans quarterly and as needed to ensure they adhere to state regulations.