Print Inspection: 0J3R

The findings of the re-licensure survey, conducted 01/08/24 through 01/10/24, 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 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

MCC:Memory Care Community

mg:milligram

ml:milliliter

MT:Medication Technician

OT:Occupational Therapist

PT: Physical Therapist

PRN:as needed

qd:every day or daily

qid:four times a day

QI:     quality improvement

RCC:       Resident Care Coordinator

RN:     Registered Nurse

TAR:     Treatment Administration

Record

tid:           three times a day

The findings of the re-visit to the re-licensure survey of 01/10/24, conducted 04/08/24 through 04/09/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and 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 revisit to the re-licensure survey of 01/10/24, conducted on 06/25/24, 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, interview, and record review, it was determined the facility failed to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and created opportunities for active participation in the community at large. Findings include, but are not limited to:

During the survey, the facility was home to 16 residents. Resident observations were made between 01/08/24 through 01/10/24, the activity calendar was reviewed, and staff were interviewed. The following was revealed:

a. The January 2024 Activity Program calendar provided to the survey team indicated the following activities would occur on 01/08/24:

* 1:00 pm - Bingo;

* 3:00 pm - Balloon Toss; and

* 4:00 pm - Crossword.

On 01/08/24, the scheduled activities were not observed, no caregiver lead activities were observed, and residents mostly remained in their rooms.

b. On 01/09/24, the activity calendar noted the following activities would occur:

* 10:00 am - Craft Corner;

* 11:00 am - Brain Games;

* 1:00 pm - Tuesday Trivia;

* 3:00 pm - Yoga with Judy; and

* 4:00 pm - Coloring.  

The only facility led activity observed was "Yoga with Judy" which took place in the adjacent MCC. No residents from the assisted living participated. Residents continued to remain in their rooms for most of the day except for during meals.

c. On 01/09/24 at 3:50 pm, Staff 9 (Interim Life Enrichment Coordinator) reported she worked Tuesday through Saturday, and caregiving staff were to provide resident activities on her days off. On 01/09/24 at 1:00 pm, Staff 5 (CG/MA) reported the caregiving staff did not have time to complete resident activities, in addition to their caregiving duties.

d. Interviews with residents revealed the following:

* On 01/08/24 at 3:06 pm, Resident 2 reported the facility had an activity calendar for the month, but it often changed. Bingo was scheduled for 01/08/24, but it was canceled; and

* In interviews with multiple un-sampled residents on 01/09/24, they indicated the Life Enrichment Director had left her position. Since then, there had not been a consistent program of activities provided.

Failure to provide a daily activity program of social and recreational activities based on individual and group interests, physical, mental and psychosocial needs, and that created opportunities for active participation in the community at large was discussed with Staff 1 (Administrator) on 01/10/24 at 11:50 am. She acknowledged the findings.

New Life Enrichment Coordinator (LEC) will be hired and trained.

All staff will be re-trained to review daily activity calendar and assist if needed or if LEC is not present.  Per policy, LEC will track activity attendance

Weekly

LEC and Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. This is a repeat citation. Findings include, but are not limited to:

During the survey, 04/08/24 through 04/09/24, observations of the facility showed one group activity, which consisted of a visiting musician, was conducted inside the memory care unit.

The facility Daily Activity Rolls for April were reviewed. The Daily Activity Rolls were blank for April 4th, 5th, 6th, and 7th.  

The April Activity calendar had Yoga, balloon toss, and crosswords scheduled for 04/08/24. None of the activities were conducted.

Multiple residents interviewed individually on 04/09/24 indicated there were limited opportunities for activities.

In an interview on 04/08/24, Staff 1 (Interim Administrator) indicated the Staff 10 (Life Engagement Coordinator) was new to the position and developing the program. She explained Staff 10 also assisted with covering the floor during staff shortages.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 and Staff 10 (Life Engagement Coordinator) on 04/09/24. The staff acknowledged the findings.

Activities Calendar will reflect activities offerred.  Activities will be incorporated into the daily routine.

New staff will receive training from LEC on how to document activities daily.  LEC will review activity logs and will retrain as needed.

Weekly

LEC and Administrator

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

There was no evidence the facility had fully implemented an ABST that would determine a staffing plan to meet the 24-hour scheduled and unscheduled needs of the residents. All facility residents were not entered into the tool.

The requirements of the ABST were discussed with Staff 1 (Administrator) on 01/08/23. She acknowledged the facility failed to ensure a staffing tool was in place, fully implemented with all residents accurately entered, to determine needed staffing.

Training on new ABST tool will be completed and tool will be implemented

New ABST tool is being implemented, data entered and training given.  Once completed, it will be used

Monthly

Administrator

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly-hired staff (#15) had completed pre-service dementia training. Findings include, but are not limited to:

Staff training records were reviewed on 04/08/24 and 04/09/24.

Staff 15 (MA), hired 03/07/24, lacked documented evidence of completing pre-service dementia training.

The need to ensure staff completed all required pre-service training was discussed with Staff 1 (Interim Administrator) on 04/09/24. She acknowledged the findings.

Preservice orientation will be completed prior new staff working independently.

Trainings, certifications, and skill competancy lists will be entered into the CC system and audited by the Community Relations Manager weekly for new hires and all neccesary trainings will be completed prior to being put on the schedule independently.

Weekly and prior to being put on the schedule independently.

Community Relations Manager and Administrator

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 5, 8, and 10) had demonstrated satisfactory performance in their assigned duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 01/09/24 and 01/10/24.

Staff 5 hired 10/09/23, Staff 8 hired 11/10/23, and Staff 10 hired 10/9/23, all MAs, lacked documented evidence of demonstrating competence in all job duties, including medication pass, within 30 days of hire. All staff demonstrated competence in medication pass on 01/09/23.

The need to ensure staff demonstrated competence in all job duties within 30 days, was discussed with Staff 1 (Administrator) on 01/10/24. She acknowledged the findings.

All staff training, certifications and skills checklists, per CPM policy, will be brought up to date.  Requirements will be reviewed with staff

Training, certifications and skills lists will be entered in (CC) Communicare system and audited

Monthly

Office Manager and Administrator

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly-hired staff (#15) had documentation of demonstrating competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 04/08/24 and 04/09/24.

Staff 15 (MA), hired 03/07/24, lacked documented evidence of  demonstrating competence in all job duties, including medication pass, within 30 days.

Staff 1 (Interim Administrator) explained Staff 15 was working independently and passing medications.  Staff 15 demonstrated competence in medication pass on 04/09/24 prior to beginning her shift.

The need to ensure staff demonstrated competence in all job duties within 30 days was discussed with Staff 1 (Interim Administrator) on 04/09/24. She acknowledged the findings.

All training and certifications required within 30 days of hire will be completed by staff or they will be taken off the schedule until they are completed.

Community Relations Manager will be entering the trainings into the CC system and will do an audit at the 30 day mark for all new employees to ensure compliance with regualtions.

monthly and withine 30 days of hire for new hires.

Community Relations Manager and Administrator

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled caregiving staff (#s 12 and 13) completed 12 hours of annual in-service training related to the provision of care for persons in a community-based care setting. The facility failed to ensure 3 of 4 long term staff (#s 7, 12, and 13) had completed annual training on infectious disease outbreak and infection control. Findings include, but are not limited to:

Staff training records were reviewed on 01/09/24 and 01/10/24.

a. Staff 12 (CG) hired 08/27/20, and Staff 13 (MA) hired 10/06/20, lacked evidence of 12 hours of annual in-service training based on anniversary of hire dates.

b. Staff 7 (Cook) hired 09/15/20, Staff 12 (CG) hired 08/27/20, and Staff 13 (MA) hired 10/06/20, lacked evidence of completing annual Infectious Disease Prevention training.

The need to ensure staff completed annual training, including training on infectious disease outbreak and infection control, was discussed with Staff 1 (Administrator) on 01/10/24. She acknowledged the findings.

All staff training and certification will be completed, including annual continuating education.  Requirements will be reviewed with management and staff

Audit training of each employee, using training tracker in CC

Monthly

Office Manager and Administrator

Based on interview and record review, it was determined the facility failed to conduct fire drills at different times of the day, evening, and night shifts. Findings include, but are not limited to:

Fire drill records for 06/10/23 - 12/21/23 were reviewed.

All drills were conducted between 4:52 am and 8:21 am. No drills were conducted on the evening shift.

In an interview with Staff 4 (Maintenance Supervisor) on 01/09/24, he acknowledged there were no fire drills conducted on the evening shift.

The need to ensure the facility was in compliance with all required fire drill requirements was discussed with Staff 1 (Administrator) on 01/10/24. She acknowledged the need for fire drills on all shifts.

Fire Drills will be conducted on evening shift.  Current policies and procedures for Fire and Life Safety Drills will be reviewed.

Per CPM procedure, drills will be conducted on rotating shifts so all shifts receive training

Monthly

Maintenance and Administrator

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents at least annually in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 01/09/24 and an interview with Staff 4 (Maintenance Supervisor) identified there was no documented evidence training on fire safety was provided to residents at least annually.

On 01/10/24 the need to provide and document fire safety instruction to residents at least annually, in accordance with the OFC, was discussed with Staff 1 (Administrator). She acknowledged the findings.

Conduct annual fire and life safety training with residents.  Retraining current requirements to conduct annual training with residents

Annual training will be documented in CC and added to audit schedule

Annually

Maintenance and Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 242 and C 372.

Individual citations and areas noted will be corrected per POC