The findings of the re-licensure survey conducted 02/07/22 through 02/09/22 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 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 first revisit to the relicensure survey of 02/09/22, conducted 11/02/22, 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.

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 revisit to the re-licensure survey of 02/09/22 conducted, 02/01/23, are documented in this report. It was determined the facility was in compliance with the 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 exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents and implement effective methods of infection control. Findings include, but are not limited to:

1. On 02/07/22 at 9:30 am, care staff were observed providing linen changes for a resident on the unit. Care staff were observed carrying soiled linens through the hallway without placing the linens in a plastic bag. A blanket was observed dragging along the floor as care staff took the linens to the laundry room.

2. On 02/07/22, soiled incontinent products were observed in an open trash can in room 30. The soiled products were not properly bagged for disposal. The sheets on the bed were observed to be stained.

3. On 02/07/22, staff were observed transporting a resident from the shower room using a shower chair. A trail of liquid was on the floor from the shower room to the resident room and there was a strong odor of urine.

4. On 02/09/22 at 11:50 am, staff were observed placing a bag of soiled incontinent supplies on the floor in the hallway. The bag of soiled supplies remained on the floor for more than 10 minutes.

5. During the survey, multiple hand washing stations throughout the facility did not have paper towels.

6. Multiple staff were observed wearing visibly soiled face shields.

The need to implement effective infection control practices was reviewed with Staff 1 (Administrator) on 02/09/22. No additional information was provided.

A.C160 Reasonable Precautions (soiled trash & linens handling, resident transport post shower, handwashing stations out of paper towels, dirty face shields)

1.What actions will be taken to correct the rule violation?

i.All staff Inservice training will be held to review expectations of infection control practices.

ii.Paper towels were refilled immediately

2.How will the system be corrected so this violation will not happen again?

i.Quality assurance checks will be added to the shift supervisor daily check off sheet & new hire training will be completed on these issues at orientation

ii.Paper towel refilling will be added to housekeeper daily check off sheet and nighttime caregiver check off sheet along with hiring of additional housekeeping staff for weekends

3.How often will the area needing correction be evaluated?

i.Daily by shift supervisors

ii.Paper towels daily by housekeeping staff & caregivers

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Day shift, swing shift & noc shift supervisors

ii.Paper towels by housekeepers

2. Resident 2 was admitted to the facility in August 2021 and had diagnoses including neuropathy and hypertension.

Observations and interviews on 02/07/22 and 02/08/22 showed the resident had two half-rails in the "up" position on either side of the bed and was wearing a nasal cannula with oxygen flowing via concentrator. The resident had an over-the-bed table with a lunch meal and was feeding him/herself a sandwich.

The current service plan, dated 01/04/22, and temporary service plans were reviewed. The service plan did not provide clear instructions to staff in the areas of:

* Use of side rails; and

* Use of oxygen/concentrator.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) on 02/08/22. She acknowledged the findings.

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 direction to staff regarding the delivery of services for 3 of 3 sampled residents (#s 1, 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in August of 2020 with a diagnosis of pain.

Resident 1's service plan was reviewed. The service plan, dated 11/09/21, was not reflective of the resident's status and lacked clear instructions to staff in the following areas:

* Pain and pain related to behaviors; and

* Side rail use as a mobility device.

The need to ensure service plans were reflective and included clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

3. Resident 3 was admitted to the facility in June 2021 with diagnoses including

Type 1 Diabetes Mellitus and below the knee amputation.

A review of the current service plan dated 01/18/22, check in guidelines dated 06/16/21 and interviews with the resident and staff were conducted during the survey.

The service plan did not provide clear instructions to staff in the areas of:

* Catheter care instructions, including steps for proper infection control; and

* Pain, including non-pharmaceutical interventions for pain and how the resident expresses pain.

The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

B.C 260 Service Plan (information on pain & pain related to behaviors, side rail usage catheter care & infection control, oxygen equipment use & infection control)

1.What actions will be taken to correct the rule violation?

i.Service plans were updated to include above information or instructions to where these treatments are located in the MAR

2.How will the system be corrected so this violation will not happen again?

i.These sections will be added to the E template for the service plans

3.How often will the area needing correction be evaluated?

i.Quarterly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Resident Care Manager and Director of Nursing

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 2 of 3 sampled residents (#s 2 and 3) whose medication records were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in August 2021.

Resident 2's MARs, reviewed from 01/01/22 - 02/07/22, revealed the following inaccuracies:

Reasons for use was not indicated for the following medications administered by unlicensed staff:

* aspirin;

* Calcium + D3;

* ibuprofen;

* sennosides - docusate sodium; and

* extra strength Tylenol.

On 02/08/22, the need to ensure all medications on the MAR included reasons for use was discussed Staff 2 (Director of Nursing) and Staff 1 (Administrator). They acknowledged the findings.

2. Resident 3 moved into the facility in June 2021.

Resident 3's MARs, reviewed from 01/01/22 - 02/07/22, revealed the following inaccuracies:

Reasons for use was not indicated for the following medications administered by unlicensed staff:

* acidophilus;

* cetirizine; and

* multiple vitamin-minerals.

On 02/09/22, the need to ensure all medications on the MAR included reasons for use was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager). They acknowledged the findings.

C.C310 Medication Administration (missing reasons for use)

1.What actions will be taken to correct the rule violation?

i.Reasons for use that have not been provided by physician were added as a special note to MAR

2.How will the system be corrected so this violation will not happen again?

i.Facility will no longer wait on physician to reply with reason for use and will list as a special note

3.How often will the area needing correction be evaluated?

i.Quarterly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Director of Nursing

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

Review of fire drill and fire and life safety records from August 2021 through December 2021 identified the following:

* The facility failed to provide fire and life safety instruction to staff on alternate months: and

* Failed to provide evidence that fire drills were conducted every other month.  

The need to ensure the facility documented all required elements for fire drills was reviewed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

D.C420 Fire Life & Safety Drills & Instruction

1.What actions will be taken to correct the rule violation?

i.All staff Inservice to review fire life & safety training

2.How will the system be corrected so this violation will not happen again?

i.Added to maintenance monthly QA and monthly inservice schedule

3.How often will the area needing correction be evaluated?

i.Monthly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Maintenance Supervisor & Administrator

Based on 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 513.

Please refer to C513

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit, all exterior pathways and accesses to the facility's common use areas were maintained, and exterior grounds were orderly, free of litter and refuse. Findings include, but are not limited to:

The facility grounds were toured on 02/07/22 with Staff 1 (Administrator) and Staff 5 (Maintenance Supervisor). The following was observed:

* A janitor's closet, located in a hallway near resident rooms, was observed to be unlocked and contained cleaning chemicals;

* Rubbish was observed on the ground near the front entrance, near both smoking sections, and throughout the parking lot;

* Cigarette butts littered the parking lot and planter boxes;

* The interior courtyard (off the dining room) had piles of leaves, tree branches and an improperly stored hose laying on the pathway; and

* Interior courtyard (near boiler room) had unmanaged landscaping, overturned containers, window screens on the ground, refuse and litter in piles on the ground.

The need to ensure all toxic materials were maintained in locked storage, exterior pathways did not have potential tripping hazards and exterior grounds were kept free of litter was discussed with Staff 1 and Staff 5 on 02/07/22. They acknowledged the findings.

E.C510 General Building Exterior (chemical room, trash & cigarette buts, courtyards)

1.What actions will be taken to correct the rule violation?

i.Chemical Room- closed and locked, all staff Inservice

ii.Trash & cigarette buts- immediately picked up by housekeeping staff

iii.Courtyards- landscapers came to clean up courtyard on 2/21/2022 and storage bin purchased to organize landscaping supplies

2.How will the system be corrected so this violation will not happen again?

i.Chemical Room- automatic closer installation

ii.Trash & cigarette buts- Will be added to housekeeper daily check off sheet and nighttime caregiver check off sheet along with hiring of additional housekeeping staff for weekends

iii.Courtyards- landscaping has been set up for ongoing upkeep

3.How often will the area needing correction be evaluated?

i.Chemical Room- monthly

ii.Trash & cigarette buts- daily

iii.Courtyards- quarterly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Chemical Room- Maintenance Supervisor

ii.Trash & cigarette buts- Housekeeper & Caregiver

iii.Courtyards- Housekeeper

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair and the interior of the facility was free from unpleasant odors. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 02/07/22 with Staff 1 (Administrator) and Staff 5 (Maintenance Supervisor).

a. The following interior areas of the facility needed cleaning and/or repair:

* Gouges, dark brown splatter and black marks on the white walls beneath the handrails through the entire building;

* Handrails throughout the facility had large spots where the finish had worn off;

* Multiple lights not working in the dining room, common hallways, and in resident rooms 19 and 21;

* Multiple ceiling lights were missing covers;

* Exposed electrical wires in room 30's bathroom ceiling;

* Exposed electric wires in the laundry room ceiling;

* Multiple ceiling tiles were broken and had brown stains throughout the building;

* Multiple ceiling vents had buildup of dust debris;

* Multiple cold air return vents on the walls had buildup of dust, debris;

* Gouges in multiple resident doors throughout the building;

* Black fabric storage bin in the dinning room had dried tan-colored stains;

* Multiple brown chairs in the dinning room and living room had torn fabric; and

* Fire doors on the north and south side of the building had multiple gouges.

b. North shower room needed the following repairs:

* Caulking around the sink was peeling and the sink was pulled away from the wall;

* Transfer pole near the toilet had peeling paint and exposed rust;

* Seal between floor and shower stall was worn with exposed subfloor underneath;

* Linoleum floor had dark gray stains and was peeling with exposed subfloor underneath;

* Door was splintered and had multiple gouges in the wood; and

* Door frame had peeling paint and exposed rust areas.

c. South shower room needed the following repairs:

* Caulking around the sink was peeling and the sink was pulled away from the wall;

* Seal between floor and shower stall was worn with exposed sub floor underneath;

* Linoleum floor had dark gray stains and was peeling with exposed subfloor underneath;

* Wallpaper (above the shower stall) was peeling with exposed sheet rock underneath;

* Ceiling vent had buildup of dust debris; and

* Ceiling support beam (south side of the building, near the shower room) had gouges in the wood and broken trim.

d. From 02/07/22-02/09/22, there was a pervasive odor of marijuana throughout the facility.

e. The following exterior areas of the facility needed cleaning and/or repair:

* Multiple windows were missing screens or the screens were torn;

* Several of the screens had a buildup of cobwebs and insects between the screens and windows;

* Multiple window seals were worn and aluminum window frames were broken;

* Multiple areas of the gutter system were damaged at the roof line and multiple down spouts were disconnected; and

* UV protectant on multiple windows was peeling off.

The need to maintain the interior and exterior of the facility in clean condition and in good repair was discussed with Staff 1 and Staff 5. They acknowledged the areas that needed cleaning and repair.

F.C513 Doors & Walls (doors, walls, wainscoting & handrails, lighting, electrical wires, ceiling tiles, vents etc.)

1.What actions will be taken to correct the rule violation?

i.The Floor Store hired to replace bathroom flooring

ii.Vortex doors has been hired to replace doors

iii.Itech Painting Pros will be hired to complete repair and repaint of wainscotting, handrails and doors.

iv.Maintenance to complete rest of repairs to lighting, electrical wires, celling tiles and vents.

2.How will the system be corrected so this violation will not happen again?

i.Added to Maintenance QA

3.How often will the area needing correction be evaluated?

i.Monthly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Maintenance Supervisor & Administrator

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior and exterior of the facility was toured on 11/02/22 with Staff 5 (Maintenance Supervisor).

a. The following interior areas of the facility needed cleaning and/or repair:

* Multiple ceiling vents had build-up of dust debris; and

* Multiple brown chairs in the dinning room and the couch in the living room had torn fabric.

b. South shower room needed the following repairs:

* Sink was pulling away from the wall; and

* Door frame had areas of paint missing.

c. The following exterior areas of the facility needed cleaning and/or repair:

* Multiple windows were missing screens; and

* The down spout on the corner of the building by the smoking area was damage and disconnected.

The need to maintain the interior and exterior of the facility in clean condition and in good repair was discussed with Staff 4 (Administrative Assistant) and Staff 5. They acknowledged the areas that needed cleaning and repair.

a.Ceiling vents- vents will be cleaned or replaced

b.Living area furniture- furniture will be replaced

c.Shower room- repairs will be made to sink and door frame paint redone

d.Screens-screens will be replaced

e.Downspout-Amazon hit the building last week and we are working with their insurance to repair the damage.

2.

a.Ceiling vents- vents will be added to housekeeping check off sheet

b.Living area furniture- will be added to administrative assistant checkoff sheet

c.Shower room- will be added to administrative assistant checkoff sheet

d.Screens- will be added to administrative assistant check off sheet

e.Downspout-attempt to move drain spout to location not hit by delivery trucks, add spouts to administrative assistant check off sheet

3.

a.Ceiling vents- monthly

b.Living area furniture- monthly

c.Shower room- monthly

d.Screens- monthly

e.Downspout-monthly

4.

a.Ceiling vents- housekeeping

b.Living area furniture- administrative assistant

c.Shower room- administrative assistant

d.Screens- administrative assistant

e.Downspout- administrative assistant

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals and provide heating systems capable of maintaining 70 degrees Fahrenheit in resident areas. Findings include, but are not limited to:

1. Observations during the survey from 02/07/22 through 02/09/22 revealed temperatures inside the building were consistently below 70 degrees during daytime hours. Temperatures obtained included the following:

* 02/07/22 at 12:15 pm, room 18 was 64 degrees;

* 02/09/22 at 9:00 am, the hallway near room 19 was 65 degrees;

* 02/09/22 at 9:15 am, the common area TV room was 65 degrees.

In separate interviews on 02/09/22, Residents 2 and 3 stated their rooms were cold.

2. During interviews on 02/07/22, care staff reported multiple resident rooms did not have heating devices. The facility was providing space heaters for the resident's use to heat the rooms as needed. On 02/09/22, a space heater was observed in use on the floor in room 18, near the resident's bed. The surface temperature of the heater was obtained and was 214 degrees Fahrenheit.

The need to ensure resident areas could be maintained at a minimum of 70 degrees and that any covers, grates or heating elements on heating devices did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) on 02/09/22. She acknowledged the findings and stated the facility planned to have PTAC units installed in resident rooms.

G.C540 Heating & Ventilation

1.What actions will be taken to correct the rule violation?

i.Direct Supply working on bid along with the already approved grant to purchase individual ptac units for all resident rooms.

2.How will the system be corrected so this violation will not happen again?

i.New hvac system will be checked and maintained and this will be added to the monthly maintenance QA

3.How often will the area needing correction be evaluated?

i.Monthly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Maintenance Supervisor & Administrator

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 02/07/22 through 02/09/22 revealed the following exit doors failed to have an alarm or other acceptable system to alert staff when residents exited the building.:

* North and south side exit doors (exit doors required a code to exit). The exit door code was posted on the wall by each door and multiple non-sampled residents were observed to enter and exit the coded doors.

* Door off the main hallway (near the kitchen), led through a small corridor, to an exit door that was not alarmed; and

* Interior courtyard exit doors (near boiler room and off the dining room) were not alarmed.

During an interview with Staff 6 (CG), s/he confirmed there were not alarms on the north exit door, south exit door, or courtyard exit doors, however there were alarms on other exit doors.

The need to ensure exit doors were equipped with an alarming device or other acceptable system was discussed with Staff 1 (Administrator) and Staff 3 (Resident Care Manager) on 02/09/22. They acknowledged the findings.

H.C555 Door Alarms

1.What actions will be taken to correct the rule violation?

i.Door alarm bells have been purchased and will be installed

2.How will the system be corrected so this violation will not happen again?

i.Added to monthly QA

3.How often will the area needing correction be evaluated?

i.Monthly

4.Who on your staff will be responsible to see that the corrections are completed/monitored?

i.Maintenance Assistant