The findings of the relicensure survey, conducted 11/15/21 through 11/17/21, 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 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

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 11/17/21, conducted 02/02/22  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.

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

On 11/15/21 at 9:30 am, the facility kitchen was observed to need cleaning or repair in the following areas:

* Floors throughout the kitchen, including dry storage, walk-in refrigerator, and freezer and underneath the beverage station had black matter buildup and food debris in corners, around perimeter edges, under equipment, inside floor drains, and in between tile grout;

* The juice dispenser had a metal shelf with chipped paint, and rust had developed around the rim where the shelf attached to the machine;

* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, splatters, dirt, dust, and debris;

* Pipes behind multiple appliances had grease, dirt, and debris on them;

* Caulking around the stainless-steel edge of the dishwashing area was black;

* Ceiling vents had an accumulation of lint and dust on the grates; and

* Chipped paint and black smears on the kitchen doors and frames.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (ED), Staff 18 (Regional Director of Operations), and Staff 19 (Corporate Office) on 11/17/21. The findings were acknowledged.

1) The kitchen has been deep cleaned. Inservicing conducted with kitchen and Memory Care staff to review cleaning schedule. Repainting and repairs will be completed for items noted in the survey.

2) Routine walkthroughs of both the main kitchen and memory care kitchenette will be conducted to evaluate for effective cleaning and verify cleaning schedules are being followed

3) Daily for 30 days then resume weekly

4) ED or designee

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear instructions for staff as to what, when, how and how often services would be provided for 1 of 5 sampled residents (#3) whose service plans were reviewed. Findings include, but are not limited to:

Observations of resident care on 11/15/21 through 11/17/21, interviews with staff, and review of the resident's current service plan and temporary service plans were conducted during the survey.

Resident 3's current service plan dated 10/5/21, was not reflective of the resident's current care needs and lacked clear instructions for staff in the following areas:

* Falls;

* Cognitive status;

* Ability to use call system;

* Bathing assistance provided by hospice; and

* Weight loss interventions.

The need to ensure service plans were reflective of the resident's current care needs and provided clear instructions to staff was discussed with Staff 1 (ED), Staff 3 (Assisted Living Director), Staff 5 (RN), and Staff 18 (Regional Director of Operations) on 11/17/21. They acknowledged the findings.

1) Updated resident's service plan to reflect resident 2 and resident 3's current care needs and provided clear instructions on all care needs

2) Staff training Inservices provided to care staff, care supervisor and ALD on the entire service plan process.

3) weekly for 30 days then resume to quarterly and as often as needed

4) utilize an interdisciplinary team comprised of ED, RN, and designee (resident and POA if they wish)

Based on observation, interview and record review, it was determined the facility failed to monitor interventions related to resident changes of condition for 2 of 4 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in June 2019 with a diagnosis including diabetes. Progress notes, incident reports, service plans and temporary service plans were reviewed during the survey.

Resident 2 experienced 5 falls between 08/18/21 and 11/15/21. Most of the falls were unwitnessed and a result of the resident having low blood sugars. Incident reports, progress notes, and temporary service plans identified interventions to mitigate falls, however, the records lacked evidence that interventions were being monitored for effectiveness after each subsequent fall.

On 11/17/21, the need to ensure interventions are monitored for effectiveness was discussed with Staff 1 (ED) and Staff 5 (RN). They acknowledged the findings.

2. Resident 3 was admitted to the facility in January 2020 with diagnoses including dementia.

A review of Resident 3's weight records revealed a significant weight loss from 9/20/21 to 10/18/21, when s/he lost 7.53% total body weight.

Resident 3's current service plan, dated 10/5/21 and temporary service plans included the following instructions and/or information for staff:

* No food preferences;

* Ensure ordered, med aids to give;

* Observe and report clothes hanging loose, weakness, sleeping more, encourage and assist to meals in dining room; and

* Cut food into bite size pieces and make sure s/he is eating.

During lunch meal observations on 11/16/21, breakfast and lunch meal observations on 11/17/21 the resident was provided food items that were cut in bite size pieces however, the resident continued to only take 3-4 bites during each meal. There were no observations of care staff ensuring the resident was eating.

Review of 11/1/21 through 11/16/21 MAR revealed the order for Ensure nutritional supplement was discontinued on 11/9/21.

During an interview on 11/16/21, two care staff reported Resident 3 will always eat grapes, crackers and things that s/he can pick up easily with his/her hands.

There was no documented evidence Resident 3's weight loss interventions had been consistently monitored for effectiveness, new interventions attempted and documented, included resident-specific instructions communicated to staff, or the service plan updated with interventions related to declining nutritional intake and weight loss interventions.

The need to ensure weight loss interventions were monitored for effectiveness, new interventions attempted and documented and resident-specific instructions communicated to staff, or the service plan updated with interventions was discussed with Staff 1 (ED), Staff 3 (Assisted Living Director), Staff 5 (RN), and Staff 18 (Regional Director of Operations) on 11/17/21. They acknowledged the findings.

1) Resident #2:  Residents fall history and effectivenes of current interventions was re-evaluated and documented in the residents record.  Resident #3: Residents weight loss and interventions have been reviewed for effectiveness and/or additional interventions identified and documentation placed in residents record.  A review of current residents who have had significant changes in condition in the last 30 days will be re-evaluated and documentation made in progress notes regarding effectiveness and/or changes to current interventions.  

2)  Re-education was provided to ALD and Nurse regarding use of the alert charting process and weekly oversight/documentation for changes of condition to assure understanding and ongoing compliance.  Routine review of changes of condition and weekly evaluations of each plans effectiveness will be conducted and documented in the residents progress notes until either stable or issue has resolved.

3) Progress notes and TCP's/service plan interventions will be audited at least weekly with f/u notes.

4) ALD and Nurse with ED oversight

Based on interview and record review, it was determined the facility failed to ensure 1 of 4 newly hired direct care staff (#8) had demonstrated competency in all required areas within 30 days of hire, and 3 of 4 newly hired staff (#s 14, 16 and 17) completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 11/16/21 and 11/17/21 and revealed the following:

a. There was no documented evidence Staff 8 (MT) hired 6/29/21 had demonstrated competency in all required areas within 30 days of hire, including:

* The role of service plans in providing individualized resident care;

* Providing assistance with the activities of daily living;

* Changes associated with normal aging;

* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;

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

* General food safety, serving and sanitation; and

* Medication and treatment administration.

Records showed Staff 8 completed these areas of demonstrated competency on 10/09/21, which was 101 days from the hire date.

b. Training records for Staff 14 (MT) hired 1/30/21, Staff 16 (CG) hired 9/21/21, and Staff 17 (CG) hired 10/13/21 lacked documented evidence first aid and abdominal thrust training was completed within the required 30 days of hire.

On 11/16/21, records received for Staff 14, Staff 16, and Staff 17 identified first aid and abdominal thrust training had not been completed until that same day, 11/16/21.  

The need to ensure all training was completed within required timeframe's was discussed with Staff 1 (ED), Staff 5 (RN), Staff 18 (Regional Director of Operations), and Staff 19 (Corporate Office) on 11/17/21. They acknowledged the findings.

1) All staff will have all required new hire training completed by 01/16/2022 to bring them back into  compliance

2) Weekly, a new hire orientation training will be held for all newly hired staff. At this orientation, all staff will be trained on items that are compliant with the new hire training requirements.

3) Weekly, all staff training records will be reviewed by ED or designee to ensure staff are fully compliant with new hire training requirements.

4) ED or designee

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 long-term staff (#12) completed the minimum required 12 hours of annual in-service training. Findings include, but are not limited to:

Facility training records were reviewed on 11/16/21 and identified Staff 12 (CG) hired on 6/10/20 lacked documented evidence of completing six hours of the required 12 hours of annual training related to the provision of care in CBC.

The need to ensure all long-term staff completed the minimum required 12 hours of annual in-service training was discussed with Staff 1 (ED), Staff 5 (RN), Staff 18 (Regional Director), and Staff 19 (Corporate Office) on 11/17/21. They acknowledged the findings.

1) All staff will have all required ongoing training completed by 01/16/2022 to bring them back into  complaince

2) Monthly, an in-serivce will be held for all staff. At this in-serivce, all staff will be trained on items that are compliant with the ongoing training requirements.

3) Weekly, all staff training records will be reviewed by ED or designee to ensure staff are fully compliant with ongoing taining requirements.

4) ED or designee   

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code. Findings include, but are not limited to:

Fire and life safety records for June 2021 through November 2021 were reviewed and revealed residents were not evacuated during the monthly fire drills.

Review of the simulated fire drill records revealed they lacked the following components:

* Escape route used;

* Problems encountered;

* Evacuation time-period needed; and

* Number of occupants evacuated.

The need to evacuate residents during fire drills unless there was documented evidence an alternative fire drill plan had been developed with the Oregon Fire Authority and documentation of the fire drills included all necessary components was discussed with Staff 1 (ED), Staff 18 (Regional Director of Operations), and Staff 19 (Corporate Office) on 11/17/21. They acknowledged the findings.

1) December Fire Drill held for staff and residents to include training and docmentation on escape route used, problems encountered, evacuation time-period needed, and number of occupants evacuated.

2) All Fire Drills will have the following components included: escape route used, problems encountered, evacuation time-period needed, and number of occupants evacuated.

3) monthly review

4) ED or designee   

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records reviewed on 11/16/21, for June 2021 through November 2021, lacked the following components:

* Alternate exit routes were used during fire drills; and

* The facility was not evacuating residents to a designated point of safety during fire drills.

Multiple staff interviewed on 11/16/21 revealed the facility was not evacuating residents during fire drills and staff did not know where the point of safety was to evacuate residents.    

The need to ensure all fire drills were conducted in accordance with the OFC, was discussed with Staff 1 (ED), Staff 18 (Regional Director of Operations) and Staff 19 (Corporate Office) on 11/17/21. They acknowledged the findings.

1) Fire drills conducted to ensure all staff are properly trained to meet at required fire and evacuation training and in compliance by 01/16/2022

2) Ongoing documented fire drills to include all required fire and evacuation training

3) Monthly review by the ED or designee to ensure full compliance

4) ED or designee

Based on observation and interview, it was determined the facility failed to ensure all interior furniture, materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:

The facility was toured on 11/15/21 and 11/16/21 with Staff 1 (ED). The following issues were identified:

* Gouges on walls in resident room 121, ceiling support beams on second floor near nurses station, and ceiling support beams on third floor near laundry room;

* Cracked handrails near rooms 114, 303, 325, 332, 351, near 2nd floor exit door, and 3rd floor stairwell;

* There were light colored stains on the carpet in hallway near the north-facing exit door on the third floor; and

* Round tables in resident communal seating areas on all four floors were unstable and in need of repair.

The areas needing repair were reviewed with Staff 1 on 11/16/21. He acknowledged the areas needing cleaning and repair.

1) All noted areas in survey report repaired and repainted to ensure full environmental compliance by 01/16/2022.

2) community walk through to inspect the physical plant of the building and correct any issues that arise from that walk through same day

3) ED or designee will review daily for 30 days then weekly

4) ED or designee

Based on observation, interview and record review, it was determined the facility failed to ensure soiled clothing and linens were laundered in a machine with a minimum rinse temperature of 140 degrees Fahrenheit or with a chemical disinfectant, provided a separate area with closed containers for soiled linens, provided a schedule for resident use, and provided a one-way flow of soiled linens and clothing that precludes the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

During a tour of the laundry facilities on 11/16/21 with Staff 1 (ED) the following was identified:

* There were resident laundry rooms on each floor that were simultaneously used by residents and staff;

* The resident laundry room that staff used did not provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing.

* Staff were unaware of the process for handling and laundering soiled linens and clothing;

* Staff were not using the flushing rim clinical sink (hopper) or staff laundry room that had a high temperature washer for soiled linens and clothing; and

* Observations of multiple non-sampled resident rooms indicated their were residents that required assistance with bladder and bowel incontinence.

Review of Resident 3's temporary service plan dated 10/27/21 indicated episodes of incontinence.

In an interview on 11/15/21, Staff 10 (Housekeeper), indicated she was unaware of how to wash soiled linens and clothing and that she only used the resident laundry rooms on each floor.

In an interview on 11/15/21, Staff 15 (Housekeeper), indicated she had never used the hopper sink or the staff laundry room since she was hired several months ago. Staff 15 showed surveyor the powder detergent that is used. The laundry detergent used didn't contain a chemical disinfectant. Staff 15 reported she doesn't add a chemical disinfectant to any of the clothing or linens.

The need to ensure the facility had a process in place to launder soiled resident linens and clothing and meet housekeeping and sanitation requirements was reviewed with Staff 1 on 11/16/21. He acknowledged the findings.

1) Updated signage posted for all machines in AL washrooms. Inservice training of all direct care staff and housekeepers on proper method of cleaning laundry, both soiled and non-soiled to ensure full compliance by 01/16/2022.

2) ongoing training and review of training records

3) ED or designee will review all staff training records weekly to ensure training completed for all direct care staff and housekeepinng staff   

4) ED or designee