The findings of the re-licensure survey, conducted 07/15/24 through 07/17/24, are documented in this report. The survey was conducted to determine compliance with 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 revisit to the re-licensure survey of 07/17/24, conducted 11/12/24, are documented in this report. The survey was conducted to determine 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.

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. Tag Numbers beginning with H refer to the 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 second re-visit to the re-licensure survey of 07/17/24, conducted on 05/22/25, 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 and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure residents' right to receive services in a manner that protects privacy and dignity for 2 of 2 sampled residents (#s 2 and 3) who had a shared bathroom. Findings include, but are not limited to:

Residents 2 and 3 resided in private units with shared bathrooms. The bathroom doors were sliding barn style and could not be locked to afford for privacy while in use.  

The facility had 16 resident rooms with shared bathrooms. All bathrooms in resident rooms were not lockable.

The need to ensure residents' rights to privacy and dignity were upheld was discussed with Staff 1 (Memory Care Administrator), Staff 2 (LPN), Staff 3 (RCC), and Staff 4 (Maintenance Director) on 07/15/24 and 07/17/24. They acknowledged the findings.

Based on observation and interview, it

was determined the facility failed to

ensure residents' right to receive

services in a manner that protects

privacy and dignity for 2 of 2 sampled

residents

The correction:

1) The facility will ensure that each shared bathroom has secure locks on both sides of the door for dignity.

2) The Administrator will work with the Maintance Director to order the correct locks and install locks when they arrive.

3) Staff will educated once all locks are installed on the dignity and respect for residents sharing a bathroom, and on how the locks work on each side.  

How the facility will stay in compliance:

1) Administrator and Maintenance director will perform monthly walking rounds to ensure all locks are working and intact for dignity and respect.

2) Maintenance Director will replace any broken or loose locks found on walking rounds.

3)POC approved for extension with this deficiency compliance date of 10/15/2024 by Jeanne Bristol, CBC Survey Unit..

Based on observation and interview, it was determined the facility failed to ensure residents' right to receive services in a manner that protects privacy and dignity for residents who had a shared bathroom. This is a repeat citation. Findings include, but are not limited to:

The facility had 16 resident rooms with shared bathrooms. All bathrooms in resident rooms were not lockable.

The need to ensure residents' rights to privacy and dignity were upheld was discussed with Staff 1 (Memory Care Administrator). She acknowledged the findings.

The facility requested and received approval for an extension of the Allegation of Compliance date to 01/15/25.

Based on observation and interview, it

was determined the facility failed to

ensure residents' right to receive

services in a manner that protects

privacy and dignity for residents who had

a shared bathroom. This is a repeat

citation.

We received approval from DHS for an extension to be completed by January 15, 2025. We were able to obtain an approval from FPS on October 29th 2024, for the door/lock design, we are pursuing alternative quotes to have the work completed by January 15th.

Based on observation, interview, and record review, it was determined the facility failed to immediately investigate an injury of unknown cause, document the injury was not the result of abuse or neglect, and report the incident to the local SPD office as suspected abuse for 1 of 1 sampled resident (# 3). Findings include, but are not limited to:

Resident 3 was admitted to the facility in 09/2020 with diagnoses including dementia.

Resident 3 was dependent on staff for all care and required two staff for transfers.

During the survey, Resident 3 was observed to be escorted in a wheelchair to all meals and activities.

Review of Resident 3's Observation Notes revealed:

05/23/24 - "Resident has a large size bruise about 2 inches diameter in size that carestaff saw while getting [him/her] up in the morning. The cause of the bruise is unknown..."; and

05/28/24 - A bruise was noted to left forearm by staff when providing cares. It remains unclear how bruising occurred...Abuse and neglect ruled out through internal investigation."

The Event Report completed on 05/23/24 documented "Resident has a large size bruise about 2 inch diameter in size on resident left forearm that carestaff saw while getting [him/her] up in the morning. The bruise is dark purple in color. No other signs noted at this time. Admin has been notified."

The medications administered to the resident were listed. There was no documented investigation of the bruise to reasonably concluded the physical injury was not the result of abuse.

The need to ensure injuries and incidents were investigated to rule out abuse or neglect, and reported to the local SPD office if abuse and neglect were not reasonably ruled out, was reviewed with Staff 1 (Memory Care Administrator) on 07/16/24. Staff 1 immediately reported the injury to the local SPD office.

Based on observation, interview, and record review, it was determined the facility failed to immediately investigate an injury of unknown cause, document the injury was not the result of abuse or neglect, and report the incident to the local SPD office as suspected abuse for 1 of 1 sampled resident

The Correction:

1) The Administrator will ensure that all incidents are investigated appropriately and notify SPD office with unknown causes of injuries with in 24 hours following investigation.

2) Administrator will perform a training on abuse, neglect and reporting to SPD office with staff members, and wellness team on: 8/22/2024

How the facility will stay in compliance:

1)Abuse and Neglect training through Oregon Care partners is required upon hire and will be required yearly with all staff and as needed.  

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 05/2024. The following required elements were not addressed in the initial evaluation:

* List of medications and PRN use;

* Visits to health practitioner(s), ER, hospital, or Nursing Facility in the past year;

* Personality, including how the person copes with change or challenging situations;

* List of treatments: type, frequency and level of assistance needed;

* Complex medication regimen;

* History of dehydration;

* Elopement risk or history; and

* Environmental factors that impact the resident's behavior.

On 07/16/24 and 07/17/24, the need to ensure the initial move-in evaluation addressed all required elements was discussed with Staff 1 (Memory Care Administrator) and Staff 2 (LPN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose move-in evaluation was reviewed.

The Correction:

1) A new nurse has been hired for Juniper Springs who will be training with the Administrator on how to fill the required elements of an initial assessment with each new move in.

2) The initial assessment was fixed on the 30 day assessment that shows all required elements answered by the Administrator 6/17/2024.

How the facility will stay in compliance:

1) Administrator will attend initial assessments with the nurse and or RCC and gather all required elements for the move in and ensure that all elements are entered appropriately.

2) Administrator will perfrom audits of the initial assessment after the Nurse has entered each new move in. Go over it with the nurse and make changes as needed together.

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool and to use the results of the tool to develop and routinely update the facility's staffing plan. Findings include, but are not limited to:

1. Sample Resident 2 was not entered into the ABST used by the facility to generate the staffing plan.

2. The results of the staffing tool were not used to update the staffing plan. The facility staffing plan was not equal to the plan generated by the staffing tool.

There were no staffing issues observed and resident needs were met.  

The need to ensure all residents were entered into the staffing tool, and potential inaccurate staffing calculations, were discussed with Staff 1 (Memory Care Director) on 07/17/24. She acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure all residents were entered into the staffing tool and to use the results of the tool to develop and routinely update the facility's staffing plan.

The Correction:

1) Resident missing from ABST has been entered approproately according to facility care plan on: 7/10/2024.

How the facility will stay in compliance

1) Administrator has implemented a task sign off sheet to review each time a new move in assessment as well as quarterly assessments have been completed by the wellness team and will check that the ABST matches the facility resident roster, staffing plans, and care tasks entered.

2) Admininstrator will perform quarterly audits of the ABST for resident roster, staffing plans and care tasks entered.  

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:

On 07/15/24, fire drill and fire and life safety training records for the previous six months were requested.

Review of the documentation provided identified the following:

* There was no documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, evening, and night shifts; and

* There was no documented evidence fire and life safety instruction to staff was provided on alternate months.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Memory care Administrator) and Staff 4 (Maintenance Director) on 07/17/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month, and fire and life safety instruction to staff was provided on alternate months.

The Correction:

1) Fire drills will be performed over the next several weeks on each shift to meet the state required rule.

2) A fire drill was performed by the Maintenance Director on 7/30/2024 at 10:45pm on night shift.

3) A Fire drill will be performed on 8/15/2024 on Day shift.

4) A Fire drill will be performed on 9/12/2024 On evening shift.

5) Maintenance director performed a disaster prepardness meeting on 7/30/24 for Power outtages for all staff.

How the facility will stay in compliance:

1)Administrator will review fire drill logs every month with Maintenance Director.

2) Administrator will work with the Maintenance director on coordination of proper emergency prepardeness topics specialized for Juniper Springs City area.

3) Administrator will coordinate with the Maintenance Director on the schedule for emergency prepardness meetings to be held monthly at the ALL staff meetings.

Based on observation and interview, it was determind the faciliy failed to ensure residents rights of privacy and dignity. Findings include, but are not limited to:

Refer to C 200.

Refer to C 200

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy and dignity. This is a repeat citation. Findings include, but are not limited to:

Refer to C 200.

See C200

Based on observation, interview, and record review, it was determined the facility failed to provide keys to residents for their entrance doors for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to:

Residents 1, 2, and 3 were not provided keys to their rooms.

Review the the residents' evaluations revealed they had been evaluated for the ability to keep track of a key and lock and unlock their door with a key. All three were determined not capable of keeping track of a room key.

The Individually Based Limitation process had not been completed for the residents.

On 07/16/24, Staff 1 (Memory Care Administrator) explained two of the current 23 facility residents had been provided keys. She acknowledged residents were not provided keys to their units if they were determined unable to manage the key.

All residents were provide keys on 07/16/24.

Based on observation, interview, and record review, it was determined the facility failed to provide keys to residents for their entrance doors for 3 of 3 sampled residents (#s 1, 2, and 3).

The Correction:

1) Wellness Director updated all care plans on: 7/17/2024 that state: All staff to assist resident with locking and unlocking apartment door as needed/requested.

2) Door lock key evaluations were completed by Wellness director on: 7/16/2024.

3) All apartment door keys were placed in each Memory Care resident top right drawer of the apartment for easy access.

4) Staff were educated on proper key storage and usage on how to assist the resident to use the key if they request on 7/17/2024.

How the facility will stay in compliance:

1) Administrator, RCC or Wellness team will perform monthly apartment checks for proper key storage.

2) If a key is missing, Administrator, RCC or wellness team will have maintenance replace the key.  

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 C 200, C 231, C 361, and C 420.

Refer to C 200, C 231, C 361, and C 420

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

Refer to C 200.

See C200

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 C 252

Refer to C 252