The findings of the change of ownership survey, conducted 10/09/23 through 10/12/23, 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 for 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 revisit to the change of ownership survey of 10/12/23, conducted 03/18/24 through 03/19/24, 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 57 for Memory Care Communities.
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 second re-visit to the re-licensure survey of 10/12/23 conducted 09/03/24 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.
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 third revisit to the re-licensure survey of 10/12/23, conducted 01/02/25, 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 and OARs 411 Division 57 for Memory Care Communities.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to:
On 10/10/23 at 10:30 am, the facility kitchen was observed to need cleaning in the following areas:
a. Food spills, splatters, debris, dust and black matter were observed on or underneath the following:
* The ceiling vent above the bread storage area had a significant amount of dust build-up;
* The ceiling above the prep area had significant splashes;
* The exterior (lids and sides) of the large food bins had food debris and black scuff marks;
* The flooring throughout the kitchen, including underneath the large mixer, counters, oven/stove/grill and the dishwashing area, had significant build-up of black matter;
* The oven doors, sides and knob area had food drips/splashes;
* The convection oven doors had grease drips/splatter;
* The sandwich refrigerator exterior doors and bottom shelf of interior had food drips/debris;
* The lower shelves beneath steamer, grill, serving and prep areas had food debris;
* The interior and exterior of the microwave had splatters and the counter underneath had food debris/crumbs;
* The dishwashing room had black matter on the wall behind the spray hose; and
* A three-tiered black cart with shelves which contained clean cups/glasses had significant build-up of debris.
b. The memory care kitchenette had two sticky fly strips hanging in the food service area.
c. Staff with beards were not using any type of hair restraints on their beards.
The areas were discussed with Staff 3 (Culinary Services Director) on 10/10/23. The findings were acknowledged.
1.Kitchen will be cleaned. Cleaning schedule will be set up for Food spills, splatters, debris, dust, and black matter. This schedule will include weekly cleaning. Fly strips in memory care kitchen have been removed. Beard covers will be worn for staff who have a beard.
2. Audits will be done weekly until compliance is met and maintained. Then audits will move to monthly.
3.The plan of correction will be evaluated weekly for 4 weeks. Then, twice a month for one month.
4.Aministrator and Director of Culinary services or designee
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were reflective of a resident's decision making ability, physical health status, needs and preferences for 1 of 6 sampled residents (#6) whose evaluations were reviewed. Findings include, but are not limited to:
Resident 6 was admitted to the facility in 06/2022 with diagnoses including dementia.
During the acuity interview on 10/09/23, the resident was identified to be in a sexual relationship with an non-sampled resident.
The resident's 08/01/23 quarterly evaluation was reviewed and lacked an evaluation of his/her ability to consent to a sexual relationship including monitoring for continued consent, sexual health and privacy needs and preferences.
In a 10/12/23 interview with Staff 4 (Director of Health and Wellness/RN), she verified there was no documented evidence the resident was evaluated regarding his/her ability to consent to the sexual relationship including an evaluation of the resident's needs and preferences.
On 10/12/23 the need to ensure residents were evaluated for decision making abilities, needs and preferences was discussed with Staff 1 (Assistant ED) and Staff 4. They acknowledged the findings.
1. Resident #6 chart will be reviewed. LN to request physician statement and/or psychiatric evaluation of resident #6 cognitive ability related to decision making as evidenced by sexual relationship. POA was informed on sexual relationship. Service plan and quarterly evaluation will be updated to reflect resident #6 decision making ability, physical health status, needs, and preferences.
2. Staff will be in-serviced on s/s of non-consensual relationship. Community staff to monitor for sign and symptoms of non-consensual relationship, notification process, and de-escalation interventions.
3. Review during weekly clinical meeting for 3 weeks and then quarterly thereafter.
4.Administrator, community licensed nurse and/or designee
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and there was progress noted, at least weekly, through resolution for 1 of 3 sampled residents (#2) who were reviewed for changes of condition. Findings include, but are not limited to:
Resident 2 was admitted to the MCC in 07/2018 with diagnoses including dementia.
Observations of the resident, interviews with staff, review of the resident's service plan dated 09/29/23, interim service plans and progress notes dated 07/10/23 through 10/07/23 were reviewed.
a. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:
* 08/09/23 - Discontinuation of medications following admit to hospice; and
* 08/28/23 - Bruising to right forearm.
b. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, and communication of the determined actions or interventions to staff on all shifts:
* 08/04/23 - Bruising on hand from hospital stay; and
* 09/22/23 - Skin tear to left outer ankle.
c. The following short-term changes of condition lacked documentation of progress noted at least weekly through resolution:
* 09/04/23 - Tooth loss.
The need to ensure actions or interventions for short-term changes of condition were determined, documented, communicated to staff on each shift and the changes of condition were monitored, at least weekly, through resolution was discussed with Staff 1 (Assistant ED), Staff 4 (Director of Health and Wellness/RN) and Staff 5 (Staff Nurse/LPN) on 10/12/23. They acknowledged the findings.
1. Director of Health and Wellness and/or Licensed nurse will review, update, and maintain ISP and short-term change of condition logs for resident #2. LN will monitor resident progress of short-term change of condition. DHW and/or LN to Inservice staff on ISP, notification process for resident change of condition, and documentation.
2. DHW, LN, and Administrator to review ISPs and short-term change of condition log weekly for resident 2 until resolution is implemented by LN for resident 2.
3. Resident 2 ISPs and short-term change of condition log will be reviewed during clinical meeting weekly for 3 weeks and then quarterly thereafter.
4. Administrator, community licensed nurse and/or designee.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010. Findings include, but are not limited to:
Upon entrance to the MCC on 10/09/23, the facility's documentation of monthly COVID-19 reporting on vaccination status to the Oregon Health Authority (OHA) for staff was requested. No information was provided.
On 10/12/23 at 10:00 am, Staff 1 (Assistant ED) confirmed the facility was unable to find documentation regarding the monthly COVID-19 reporting on vaccination status to OHA.
The need to ensure the facility complied with vaccination requirements as prescribed in OAR 333-019-1010 was discussed with Staff 1, Staff 4 (Director of Health and Wellness/RN) and Staff 5 (Staff Nurse/LPN) on 10/12/23. They acknowledged the findings.
1.Business Office Manager and/or designee will conduct community staff audit for vaccination status.
2.The information from the initial audits will be given to the infection control specialist. Each week business office manager will give a roster that includes new staff and their vaccination status.
3. Administrator will enter this information on the OHA portal at least monthly.
4.Administrator and/or Director of Health and Wellness.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 1 of 2 sampled residents (#3) whose MARs and Controlled Substance Disposition logs were reviewed for accuracy. Findings include, but are not limited to:
Resident 3 was admitted to the MCC in 06/2015 with diagnoses including dementia.
The resident's physician orders, the Controlled Substance Disposition logs and the MAR, dated 10/01/23 through 10/09/23 were reviewed.
Resident 3 had physician orders for the following controlled medications:
* Oxycodone 5 mg - take one tablet by mouth twice daily for pain;
* Oxycodone 5 mg - take 2.5 mg by mouth every four hours as needed for pain; and
* Lorazepam 0.5 mg - take one tablet by mouth every six hours as needed for anxiety.
The following inaccuracies were identified between the resident's MAR and the Controlled Substance Disposition log:
* 10/01/23 - Resident 3's morning dose of scheduled oxycodone was documented as given by Staff 20 (MT) in the MAR and documented as given by Staff 18 (MT) in the Controlled Substance Disposition log;
* 10/02/23 - Resident's 3's PRN oxycodone was documented as administered in the Controlled Substance Disposition log, but it was not documented in the MAR;
* 10/03/23 - Resident 3's morning dose of scheduled oxycodone was documented as administered in the MAR; however, it was not documented in the Controlled Substance Disposition log; and
* 10/05/23 - Resident 3's PRN oxycodone was documented as administered in the MAR, but it was not documented in the Controlled Substance Disposition log. The records were reviewed with Staff 1 (Assistant ED) and Staff 4 (Director of Health and Wellness/RN) on 10/10/23 at 3:00 pm. It was determined the resident was administered PRN lorazepam, not PRN oxycodone, and the medication administration was documented in the Controlled Substance Disposition log under the PRN lorazepam.
The need to ensure the facility had an effective system for tracking controlled substances was reviewed with Staff 1, Staff 4 and Staff 5 (Staff Nurse/LPN) on 10/12/23. They acknowledged the findings.
1. Staff were in-serviced on the following: Medication administration, Control substance tracking process, and Medication rights.
2. Staff in-serviced on controlled substance tracking process. Narcotic books separated by routine order and PRN orders.
3. Weekly narcotic book and EHR/EMR review.
4. Administrator and/or Licensed Nurse.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed for 2 of 4 sampled residents (#s 1 and 5) whose orders were reviewed. Findings include, but are not limited to:
1. Resident 5 was admitted to the facility in 02/2020 with diagnoses including vascular dementia and type 2 diabetes mellitus.
Resident 5's current physician orders, dated 08/28/23, and MARs from 09/01/23 through 10/09/23 were reviewed and included the following:
* Humalog 100 U/ml insulin sliding scale for diabetes was ordered for administration with midday and evening meals only based on Resident 5's blood glucose level. An incorrect dose of insulin was administered on two occasions. The administration of the incorrect dose had no negative outcome to Resident 5;
* Humalog 100 U/ml insulin was ordered for injection five units subcutaneously every morning to control blood glucose with instructions to hold if the blood glucose level was less than 120, or if the resident was not eating. PCP was to be notified if insulin was held based on the instructions. There was no documented evidence the PCP was notified on twelve occasions; and
* Blood glucose checks were ordered before every meal and at bedtime prior to the administration of insulin. There was no documented evidence the facility checked the resident's blood glucose levels on five occasions.
2. Resident 1 was admitted to the facility in 08/2023 with diagnoses including dementia, Parkinson's disease and insomnia.
Resident 1's current physician orders, dated 10/02/23, and MARs from 09/01/23 through 10/09/23 were reviewed and included the following:
* Polyethylene glycol (Miralax) powder to be administered twice daily as needed for constipation (no bowel movement in more than 24-48 hours). Based on the bowel movement record in the MARs, Resident 1 had no bowel movement on 10/06/23, 10/07/23, 10/08/23 and the morning of 10/09/23. There was no documented evidence the polyethylene glycol powder was administered.
The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (Assistant ED), Staff 4 (Director of Health and Wellness/RN), Staff 27 (RN Consultant) and Staff 5 (Staff Nurse/LPN) on 10/11/23. They acknowledged the findings. No further information was provided.
1. Resident 5 EHR/EMAR reviewed and updated to reflect physician order for sliding scale insulin. Resident 1 EMR/EHR reviewed and updated to reflect BM monitoring.
2. EMAR and BM tracking to be reviewed daily by med tech and administer PRN medication per physician order.
3. EMAR audit to be done on weekly basis by DHW and/or licensed nurse for one month.
4. Administrator, Director of Health and Wellness and/or Licensed Nurse.
There are no detail notes for this visit.
Based on observation, interview, and record review, it was determined the facility failed to implement an Acuity-Based Staffing Tool (ABST) that addressed all required ADLs and the amount of staff time needed to provide care for 1 of 1 sampled resident (#2) and multiple non-sampled residents whose ABST reports were reviewed. Findings include, but are not limited to:
1. On 10/11/23 at 9:09 am, the facility's Eldermark ABST was reviewed and discussed with Staff 1 (Assistant ED), Staff 4 (Director of Health and Wellness/RN) and Staff 28 (VP of Clinician/RN).
a. Staff 1 and Staff 4 were unable to confirm all 22 required ADLs contributed to the generated minutes used to create a staffing plan.
b. The ABST report provided for the MCC's 34 residents lacked evidence the ABST addressed all 22 required ADLs for each resident.
2. Resident 2 moved into the MCC in 07/2018 with diagnoses including dementia.
Resident 2's 10/09/23 ABST report was reviewed, observations of the resident were made, and interviews with caregivers were conducted during the survey. The ABST report did not include staff time needed to provide care for the following ADLs in which Resident 2 required assistance:
* Supervising, cueing or supporting while eating;
* Repositioning in bed or chair;
* Cueing or redirecting due to cognitive impairment or dementia;
* Monitoring physical conditions or symptoms;
* Assisting with communication; and
* Safety checks and fall prevention.
The need to have all required ADLs included on the facility's ABST with the amount of staff time needed to provide care and to ensure service plans were reflective so the ABST would be accurate was discussed with Staff 1, 4 and Staff 5 (Staff Nurse/LPN) on 10/12/23. They acknowledged the findings.
1. Executive Director created new account for ABST on Oregon state web site.
2. The community will be using the ABST provided on the Oregon state portal.
3. Administrator will update portal to be reflective of resident assessment upon move in, 30 and 90 days after move in and then with significant change of condition.
4. Administrator and/or Designee
Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) whenever a resident experienced a significant change of condition and/or no less than quarterly. This is a repeat citation. Findings include, but are not limited to:
The facility was using the Oregon Department of Human Services' ABST, which was reviewed on with Staff 1 (Assistant ED/MC1 Administrator) on 03/18/24 at 2:45 pm.
The tool's data had not been updated within the last 90 days for 12 out of 30 residents.
The need to update the ABST whenever a resident experienced a significant change of condition and/or no less than quarterly was discussed with Staff 1. She acknowledged the findings.
1) ABST Portal will be updated to reflect the resident's current needs for the 12 out of the 30 resident's.
2) Administrator and/or Designee will update the portal upon move in, 30 and 90 days after move in, and with change in contidtion. This will be completed during the intial, 30 day, Quarterly, and Change of Condition evaluation.
3) ABST will be evaluated weekly for four weeks during weekly clinical meeting.
4) Administrator and/or Designee
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 sampled newly-hired direct care staff (#s 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 10/11/23. The following were identified:
Staff 16 (CG) was hired 09/07/23,and Staff 17 (CG) was hired 09/07/23. There was no documented evidence Staff 16 or Staff 17 completed First Aid and abdominal thrust training within 30 days of hire.
The need to ensure staff completed all required training as specified in the OARs was discussed with Staff 29 (VP of Operations) and Staff 2 (Reception/Business Office Administrator) on 10/11/23. They acknowledged the findings. No other information was provided.
1. Business Office Manager and/or designee to conduct employee file audit.
2. Training will be conducted for staff as needed per audit results. BOM will collaborate with Administrator, and RN for scheduling staff training per OAR.
3. Onboarding checklist to include training per OAR. BOM and DHW to review weekly for one month.
4. Business Office Manager, Administrator and/or Director of Health and Wellness.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure unannounced fire drills were conducted and documented every other month and included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills. Findings include, but are not limited to:
Facility fire drill records dated 04/2023 through 10/2023 were reviewed with Staff 6 (Maintenance Director) on 10/11/23. The facility lacked documented evidence unannounced fire drills were conducted every other month and included the following components:
* Escape route used;
* Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills;
* Evacuation time needed;
* Number of occupants evacuated; and
* Evidence alternative routes were used during fire drills.
In addition, the facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills.
The requirement to ensure unannounced fire drills were conducted and documented every other month and included all required components and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (Assistant ED) on 10/12/23. She acknowledged the findings.
1. Fire drills and Disaster drills will be completed per OARs.
2. The Maintence Director and Administrator will be inserviced of Fire drills per OAR/OFC by Regional Maintence team. Implementation of consultant fire drill report fillable form.
3. Documentation of fire drills including
but not limited to C, D, G, E and disaster drills will be reviewed monthly during Administrator and Maintence 1:1 weekly meeting.
4. Maintence Director and/or designee.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-educated at least annually. Findings include, but are not limited to:
Fire and life safety records were reviewed on 10/11/23. Staff 1 (Assistant ED) and Staff 6 (Maintenance Director) were interviewed, and the following was identified:
There was no documented evidence residents were educated in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire within 24 hours of admission and re-educated at least annually.
On 10/12/23, the need to ensure fire and life safety instruction was provided to each resident within 24 hours of admission and at least annually as required by the Oregon Fire Code was discussed with Staff 1. She acknowledged the findings.
1.Training for residents will be completed per OAR
2.Facility fire and life safety procedures will be added to the resident move in packet and kept in resident files.
Documentation will be maintained by Maintenance staff or Administrator in regards to annual training of residents.
3.Weekly during 1:1 meeting between Administrator and Maintenance Staff.
4.Administrator and/or Maintenance staff.
There are no detail notes for this visit.
Based on observation, 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 C 361, C 513, C 530, Z 142, and Z 155.
Refer to C361, C513, C530, Z142, and Z155.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair, and the interior of the facility was free from unpleasant odors. Findings include, but are not limited to:
During a tour of the MCC on 10/09/23 at 2:40 pm the following was identified:
a. Hallway:
* A large plastic chip was missing from the half-height door to the nursing station, exposing the underlying wood composite of the door;
* Handrails throughout the MCC were worn and had exposed wood;
* The odor of urine was apparent throughout the TV and activity area; and
* The primary door to the MCC was dirty and worn, and chipped paint was visible.
b. Laundry Room:
* Utility sink was soiled;
* All pipes adjacent to the ceiling were covered with dust;
* Three 2-inch holes were visible in the drywall where the facility stated an additional sink would be installed;
* Large, rectangular opening in the drywall next to the vertical washer / dryer unit, exposing interior wall space;
* Dust covering the rear of the vertical washer / dryer unit; and
* Edge of door to the nursing office was unfinished with exposed wood.
c. Building Exterior:
* Wood framing on the walls around the exterior of the MCC, including the fenced-in patio and interior courtyard, was damaged and rotting.
The areas in need of cleaning, repair and/or odor remediation were shown to and discussed with Staff 6 (Maintenance Director) and Staff 1 (Assistant ED) on 10/10/23, and with Staff 29 (VP of Operations) on 10/11/23. They acknowledged the findings.
1. Hallways will be cleaned, repaired, and deotorized. Laundry rooms will be cleaned and repaired. Exterior areas will be cleaned and repaired.
2.Administrator and Maintenance Director will ensure interior and exterior materials and surface will be kept clean and in good standing by conducting routine walk through out the community.
3.Weekly during 1:1 meeting.
4. Administrator and/or Maintenance Director.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair, and the interior of the facility was free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:
During a tour of the MCC on 03/18/24 at 10:40 am the following was identified:
a. Hallway:
* A large plastic chip was missing from the half-height door to the nursing station, exposing the underlying wood composite of the door;
* A broken electrical cover on the wall near the nurses station;
* Multiple resident unit doors were damaged or had black and brown marks including, but not limited to: Rooms 102, 104, 106, 107, 112, 113, 114 and 123;
* Carpet was frayed in multiple areas in resident corridors including, but not limited to: corridor near room 116;
* Handrails throughout the MCC were worn and had exposed wood;
* White baseboards throughout resident corridors were damaged with exposed wood;
* The odor of urine was apparent throughout the TV and activity area;
* Multiple chairs and couches throughout the common areas were damaged, fabric was torn, and the furnishings had a strong odor;
* Multiple dining room chairs were stained and/or had gouges in the wood;
* The half wall surrounding the kitchenette countertop was damaged with gouges in the paint and wall;
* A window sill next to the interior courtyard door had chipped paint and exposed wood; and
* The interior and exterior courtyard door had scrapes, gouges and peeling paint.
b. Laundry Room:
* A large, rectangular opening in the drywall next to the vertical washer/dryer unit, exposing interior wall space;
* Dust covering the rear of the vertical washer/dryer unit; and
* Edge of door to the nursing office was unfinished with exposed wood.
c. Building Exterior:
* Wood framing on the walls around the exterior of the MCC, including the fenced-in patio and interior courtyard, was damaged and rotting.
The areas in need of cleaning, repair and/or odor remediation were shown to and discussed with Staff 1 (Assistant ED/MC1 Administrator) and Staff 31 (ED) on 03/18/24. They acknowledged the findings.
1.This POC has approval to extend the 513 tag for compliance until completion of remodel per Jeanne Bristol
2.. Community is undergoing renovation. Repair will be completed for hallway, laundry room, and exterior building.TV area and activity area furniture will be cleaned and/or replaced.
3. Maintence Director and Execuative director will walk the community and community property weekly to ensure community is clean, in good repair, establish reduction in odor.
4. Execuative Director, Maintence director and/or designee
Based on observation, interview, and record review, it was determined the facility failed to ensure the environment was maintained clean and in good repair, and the interior of the facility was free from unpleasant odors. This is a repeat citation. Findings include, but are not limited to:
A tour of the MC on 09/03/24 at 11:20 am revealed the areas identified during the first re-visit on 03/19/24 that were in need of cleaning and repair, including the interior free from unpleasant odors, had not been completed.
An extension for the areas previously cited in C513 was granted through 09/24/24.
During an interview on 09/03/24 at 11:30 am, Staff 31 (ED) acknowledged the facility had reordered all new furniture that included tables and chairs, new doors, lighting, baseboards and would address the interior and exterior of the building that was identified at the first re-visit on 03/19/24. Staff 31 was unable to provide a start date for the remodel but indicated "we estimate in three weeks or so". She confirmed the work had not yet begun.
The areas in need of cleaning, repair and/or odor remediation was discussed with Staff 31 and Staff 36 (Assistant ED/MC1) on 09/03/24 at 1:00 pm. They acknowledged the findings.
We are currently awaiting an approval date from FPS regarding the renovation of The Atrium at McLoughlin Place and turning it into all ALF rooms with a MC Endorsement. In the meantime, we will begin to transition residents from The Atrium at McLoughlin Place to McLoughlin Memory Care of Oregon starting the week of 10/14/2024, with all residents being moved over by 12/01/2024.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the soiled linen room or area included a flushing rim clinical sink with a handheld rinsing device and a hand wash sink. Findings include, but are not limited to:
During a tour of the MCC laundry room on 10/09/23 at 2:40 pm, it was observed there was only one standard utility sink in the laundry room.
In an interview with Staff 30 (Laundry Aid), she stated soiled linens were brought to the MCC laundry room, rinsed in the utility sink and then washed separately in the washing machine. Staff 30 indicated the utility sink was also used for hand washing.
The need to install a flushing rim clinical sink and have a separate hand wash sink was discussed with Staff 6 (Maintenance Director) and Staff 1 (Assistant ED) on 10/10/23, and with Staff 29 (VP of Operations) on 10/11/23. No further information was provided.
1.Installation of a flushing rim sink will be installed and a new/clean sink will be installed for handwashing.
2.Administrator and Maintenance Director will ensure staff are trained on proper usage of individual sinks for cleaning and handwashing purposes.
3.Weekly during 1:1 meeting
4.Administrator and/or Maintenance Director.
Based on observation and interview, it was determined the facility failed to ensure a separate area with closed containers for storage and handling of soiled linens and soiled clothing, separate space and equipment, including waterproof gloves for laundry personnel who handled soiled linen and soiled clothing that was separate from regular linens and clothing to precluded the potential for contamination of clean linens and clothing. This is a repeat citation. Findings include, but are not limited to:
During a tour of the MCC laundry room on 03/18/24 at 10:40 am, the following was identified:
* The clinical rim flushing sink (hopper sink for soiled linens) was observed to have brown water in it with a blue piece of clothing. There was a tall white laundry basket with clean linens and multiple clean wheelchair cushions within one inch of touching the soiled hopper sink;
* Multiple clear bags were observed in large gray bins with un-bagged clothing items; and
* There was no personal protective equipment (PPE) within the vicinity of the hopper sink for laundry personnel to use.
During an interview on 03/18/24, Staff 30 (Laundry Aide) stated soiled linens were brought to the MCC laundry room in bags and placed in laundry bins with other non-soiled clothing. They were rinsed in the hopper and a disinfectant was used in the washer. Staff 30 was asked where the PPE for soiled linens and clothing was located. Staff 30 was unable to find waterproof aprons, waterproof gloves were found in a cabinet in another room, and one pair of visibly soiled eye goggles were stored in another room hanging on a fire extinguisher.
Staff 1 (Assistant ED/MC1 Administrator) , Staff 30 and Staff 31 (ED) were shown the hopper during a tour of the laundry room on 03/18/24 at 12:20 pm. The hopper was observed to have the same brown water and blue piece of clothing.
The need to ensure a separate area with closed containers for storage and handling of soiled linens and soiled clothing that precluded the potential for contamination of clean linens and clothing and the use of waterproof equipment including gloves was discussed with Staff 1 and Staff 31. They acknowledged the findings.
1) Laundry Aide and Staff members will be in-serviced on the proper infection control for the laundry room and clinical rim flushing sink (hopper sink for soiled linens).
2) Maintenance Director and Administrator will complete an audit of the laundry room to confirm that the laundry room flow is in place and being followed.
3) This will be completed weekly for four weeks or until substantial compliance is met and maintained.
4) Maintenance Director, Administrator, and/or Designee.
There are no detail notes for this visit.
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, C295, C361, C372, C420, C422, C513 and C530.
Refer to C240, C295, C361, C372, C420, C422, C513, and C530.
Based on observation, interview, and record review, 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 361, C 513, and C 530.
Refer to C 361, C 513, and C 530.
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 C513.
Referb to C513.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly-hired staff (#s 16 and 17) completed all required pre-service training prior to beginning job duties and demonstrated competency within 30 days of hire, and 2 of 2 sampled long-term direct care staff (#s 22 and 23) completed a total of 16 hours of annual in-service training, including six hours of dementia care training. Findings include, but are not limited to:
Training records were reviewed on 10/11/23, and the following were identified:
Staff 16 (CG) was hired 09/07/23, Staff 17 (CG) was hired 07/14/23, Staff 22 (MT) was hired 09/17/19, and Staff 23 (MT) was hired 08/01/19.
a. There was no documented evidence Staff 16 and Staff 17 completed the following orientation topics:
* Infectious disease prevention;
* Fire safety and emergency procedures; and
* Acknowledgement of written job description.
b. There was no documented evidence Staff 16 and Staff 17 completed the following required pre-service training prior to providing personal care:
* Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms;
* Techniques for understanding, communicating and responding to distressful behavioral symptoms;
* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;
* Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach;
* Environmental factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.);
* Family support and the role the family may have in the care of the resident;
* How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment;
* How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and
* Use of supportive devices with restraining qualities in memory care communities.
c. There was no documented evidence Staff 16 and Staff 17 demonstrated competency within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* 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.
d. There was no documented evidence Staff 22 and Staff 23 completed infectious disease prevention training.
e. There was no documented evidence Staff 22 and Staff 23 completed the required annual in-service training, including six hours of dementia care training for the year 2022.
The need to ensure newly-hired direct care staff completed all orientation and pre-service training topics prior to beginning any job duties, demonstrated required competencies within 30 days of hire, and long-term direct care staff completed a total of 16 hours of annual in-service training, including six hours of dementia care training was discussed with Staff 29 (VP of Operations) and Staff 2 (Reception/Business Office Administrator) on 10/11/23. They acknowledged the findings. No further information was provided.
Refer to C372.
Based on interview and record review, it was determined the facility failed to ensure 1 of 2 newly-hired staff (# 35) completed all required pre-service training prior to beginning job duties and demonstrated competency within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:
Training records were reviewed on 03/19/24. The following was identified:
Staff 35 (CG) was hired 02/08/24.
a. There was no documented evidence Staff 35 completed the following orientation topics:
* Resident rights and values of CBC care; and
* Abuse reporting requirements.
b. There was no documented evidence Staff 35 demonstrated competency within 30 days of hire in the following areas:
* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation and reporting of changes of condition; and
* Conditions that require assessment, treatment, observation and reporting.
The need to ensure newly-hired direct care staff completed all orientation and pre-service training topics prior to beginning any job duties, and demonstrated required competencies within 30 days of hire was discussed with Staff 1 (Assistant ED/MC1 Administrator) and Staff 31 (ED) on 03/19/24. They acknowledged the findings.
1) Staff 35 has completed required training elements per OAR prior to the return of providing direct care.
2) Administrator will complete an audit of training requirments of new hires prior to providing direct care.
3) Administrator will review new hire checklist and training completion prior to providing direct care.
4) Administrator and/or Designee.
There are no detail notes for this visit.
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 C252, C270, C302 and C303.
Refer to C252, C270, C302, and C303.
There are no detail notes for this visit.