Print Inspection: 0KR8

The findings of the re-licensure survey, conducted 01/30/23 through 02/01/23, 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 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

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 revisit to the re-licensure survey of 02/01/23, conducted 05/17/23 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 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to provide an activity program based on individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to:

The facility was comprised of two separate cottages, connected by a common outdoor courtyard area. These were labeled as the 52 building and the 64 building.

On 01/30/23 through 02/01/23, from approximately 9:00 am through 3:00 pm the two buildings were observed for organized activities. In the 52 building a few individual activities were conducted, including nail treatments and craft work. However, there were no scheduled or unscheduled group activities observed in either building on 01/30/23, 01/31/23, or 02/01/23. On those days residents were observed in their rooms, wandering around the units, or sitting in common areas.

During the survey, an activity calendar was posted on the wall, but covered only the previous week.

In an interview on 02/01/23, Staff 1 (Administrator) indicated the facility had just hired a new Activity Director, who planned to restructure a comprehensive activity program.

On 02/01/23 the lack of an activity program was discussed with Staff 1 and Staff 3 (LPN). They acknowledged the findings and stated plans for immediate improvement.

On January 30, 2023, a new activities director was hired, followed closely by a new activities assistant hired on February 7.  The expectation for intervention strategies regarding both individual and group activities based on resident interests and physical, mental, and psychosocial needs have been trained for our new activities department.

Our Activities Director will establish a monthly calendar to support caregivers further to ensure resident engagements maintain fluidity and maximize opportunities should there be an absence or activities personnel depart from employment.

For redundancy, our Administrator, or delegate, will review all monthly activity calendars/plans to ensure a daily program of social and recreational activities are present. Each day of the week, individual opportunities and group engagements will be posted in each of the facility cottages (52 and 64, respectively). In addition, calendars will be posted prior to each new month.

To be completed and in compliance by April 2, 2023.

Based on interview and record review, it was determined the facility failed to ensure significant changes of condition were assessed by an RN for 1 of 1 sampled resident (# 3) reviewed for a significant change of condition. Findings include, but are not limited to:

Resident 3 was admitted to the facility in February 2016 with diagnoses including bipolar II disorder, dementia with behavioral disturbances, and schizophrenia.

During the entrance conference on 01/30/23 the resident was identified as having a recent decline and admission to hospice services.

Progress notes indicated Resident 3 was hospitalized from 12/17/22-12/22/22 for respiratory insufficiency. A progress note on 01/02/23 by Staff 3 (LPN) stated, "Sent over a fax to PCP regarding continued complaints of back pain/not eating [his/her] meals/sleeping more. Requesting PCP to make a visit to facility to see [resident]. Possible hospice referral." This decline constituted a significant change in condition for which an assessment by the facility RN was required.

The resident was observed during the survey to be non-verbal, communicating in grunts. Staff 6 (CG) reported in an interview that since returning from the hospital the resident had been more painful and less communicative.

In an interview with Staff 3 on 01/31/23 she reported the facility RN had not conducted an assessment for the significant change of condition.

The findings were reviewed with Staff 1 (Administrator), Staff 2 (Assistant Administrator) and Staff 3 on 02/01/23. They acknowledged the findings.

As of 2/28/23, facility RN has completed appropriate documentation regarding a significant change of condition for Resident 3 and their hospice referral. RN had noted the change of condition in prior facility LPN documentation. To meet the expectation of C280, facility RN has created additional/separate change of condition documentation.

All significant changes of conditions will be reported to the facility RN with expectations of completion within 24 hours.

The facility has created and implemented telehealth procedures in the event the facility RN is unavailable due to COVID outbreaks or another communicable disease as part of our Infection Control Program. The goal is not to cross-pollinate any contagious disease between our four communities.

Facility RN will perform either an in-person review, telehealth remote visit, or online chart review. The facility LPN, Administration, or delegate will ensure the electronic health record is up to date and available for an accurate RN chart review.

For redundancy, all communications regarding significant changes of conditions will also be sent to the facility administration and operations manager as of February 21, 2023.

Based on interview and record review, it was determined the facility failed to ensure the Administrator obtained the Residential Care Facility Administrator (RCFA) license by 01/01/22. Findings include, but are not limited to:

On 01/30/23, Staff 1 (Administrator) was asked to provide documentation of his Residential Care Facility Administrator license. Staff 1 reported he did not have the license. He reported he had completed a Department-approved classroom administrator training program of 40 hours 01/23/23-01/27/23 and would be taking the test soon.

The requirement to have a current Residential Care Facility Administrator license was discussed with Staff 1 on 02/01/23. He acknowledged the findings.

This administrator successfully completed all requirements for the RCF administrator license. Current administrator, Nathan Kelley, now has an active license: NHA RC 10230093, expiration 2/29/2024.

To ensure this lapse does not occur again, should a new administration event occur, our operations manager will be identified as the acting administrator until the successful completion of OAR 411-054-0065(3).

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation in all required topics, including pre-service dementia training, was completed prior to providing services to residents for 1 of 3 newly hired staff (#8) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 01/31/23.

Staff 8 (Caregiver), hired 11/19/22, lacked documented evidence of having completed pre-service training in abuse reporting requirements, infectious disease prevention and all pre-service dementia care topics.

On 02/01/23 the need for staff to complete all required pre-service orientation and dementia training before working with residents was reviewed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings. No additional documentation was provided.

1. Staff 8 successfully completed required trainings:

a. 1/20/23 Abuse and Neglect in Elder Care Setting

b. 1/18/23 Alzheimer's Disease and Related Disorders: Communication

c. 1/20/23 Assisting with Personal Care

d. 1/23/23 DIffering Dementias Self-Paced

e. 1/19/23 Elimination and Toileting

f. 1/19/23 Environment: Creating a Sense of Calm

g. 1/19/23 Fire Safety and Emergency Preparedness

h. 1/18/23 First Aid - Part 1

i. 1/20/23 First Aid - Part 2

j. 1/23/23 Managing Aggressive Behaviors

k. 1/20/23 Mental Health Disorders and Care of Those with Trauma

l. 1/23/23 Natural Disasters and Workplace Emergencies: An Overview

m. 1/20/23 Psychosocial Issues

n. 1/23/23 Sexual Harrassment: What Employees Need to Know

o. 1/19/23 Standard Precautions and Bloodborne Pathogens

p. 1/19/23 Understanding Mental Illness

q. 1/19/23 Understanding Resident Rights

Additional trainings and documentation available upon request.

2. These training components are conducted at our Corporate headquarters prior to arriving at our communities. All documentation of training is kept with our Human Resources Department and within our software system.

Further documentation of training available on request.

3. Our HR Department monitors all new direct care staff training weekly. New staff must complete all pre-service training in abuse reporting requirements, infectious disease prevention, and all pre-service dementia care topics prior to attending an in-person Orientation training at our Corporate office. Only once a new staff member completes all the above training are they released to our community to begin our 30-day floor training.

4. Our HR Department is responsible to ensure all the above training is completed prior to a new staff member working directly with residents.

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired direct care staff (#s 8 and 9) demonstrated competency of skills in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed on 01/31/23.

There was no documented evidence Staff 8 (Caregiver) or Staff 9 (Caregiver) had completed one or more of the following required competencies:

* 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.

The need to ensure staff had documented evidence of competency demonstration in all assigned duties within 30 days of their hire date was discussed with Staff 1 (Administrator) and Staff 3 (LPN). They acknowledged the findings. No additional documentation was provided.

As of 2/20/23, Staff 9 demonstrated compentancy with required trainings related to the following:

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;

General food safety, serving and

sanitation.

As of 2/27/23, Staff 8 demonstrated compentancy with required trainings related to the following:

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;

General food safety, serving and

sanitation.

Going forward, all new employees will successfully complete all direct care staff training before 30 days in accordance with OAR 411-054-0070 (6)(9).

All caregiver training will be reviewed by the Administrator or designee within the first 30 days to ensure compliance and optimal training. In addition, all successful staff trainings documents will be stored electronically in their appropriate individual file.  This documentation and filing will be in compliance by April, 2023.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month. Findings include, but are not limited to:

Fire drill and fire and life safety training records for the previous 6 months were requested on 01/30/23 from Staff 1 (Administrator). He reported that he did not have fire drill records, and confirmed on 01/31/23 that fire drills were not being conducted.

On 02/01/23 Staff 1 acknowledged the need to conduct fire drills every other month with the required components.

Fire drills will be conducted at least every other month at different times of the day. Our newly created Fire, Life & Safety binder will outline our procedure, expectations, and documentation of each fire drill, with all necessary documentation included in OAR 411-054-0090. This change has already taken effect.

Facility Safety Committee meets monthly and will verify that fire drills have been conducted and appropriate Fire, Life, and Safety training topics are taught during our monthly mandatory meetings. In addition, the administration or designee will ensure fire drill compliance and accuracy.  

Based on interview and record review, it was determined the facility failed to have a system for instructing residents within 24 hours of admission and re-instructing them, at least annually, in fire safety topics. Findings include, but are not limited to:

On 01/31/23 Staff 1 (Administrator) reported there was no documentation of training in fire safety for residents upon admission and did not know if residents had been provided training annually in the past.

On 02/01/23 Staff 1 acknowledged the need to provide instruction in fire safety upon admission and annually. No further information was provided.

As of 3/1/23, all residents have been instructed, or reinstructed to our facility evacuation procedures and documented. Documentation has been filed electronically in the resident file and our Fire, Life and Safety Binder.

The Administration Team will conduct a review within 24 hours of the resident's admission to ensure instruction has been given to the newly admitted resident in compliance with OAR 411-054-0090 (5). Additionally, the Administration Team will review the resident's annual re-instruction on a quarterly basis during our quarterly care conferences, and documented within their service plan to ensure to meet the annual requirements.

Based on observation and interview, it was determined the facility failed to ensure outdoor perimeter fencing was not secured to prevent exit. Findings include, but are not limited to:

During observations of the facility exterior 01/30/23-02/01/23 the grounds were noted to be accessible only through a locked gate with a coded keypad. No residents were observed exiting and entering the gate.

In a phone interview 02/02/23 Staff 1 (Administrator) confirmed that the residents did not have the code to the keypad and were not allowed to exit the grounds unattended.

The need to ensure outdoor perimeter fencing was not secured to prevent exit was discussed with Staff 1 during the phone interview. He acknowledged the findings.

McKenzie Living has always had a secure facility for those we serve. Unfortunately, our 2014 approved exception was not located by the survey team. Neither McKenzie Living nor our Policy Analyst could obtain a copy of the approved exception we have been working under.

Our Chief Operations Officer reapplied for the exception, and our Policy Analyst approved without hesitation; see our attachment.

Based on observation and interview, it was determined the facility failed to provide an exit door alarm or other acceptable system for security purposes and to alert staff when residents exited the RCF. Findings include, but are not limited to:

During an environment tour of the facility on 01/30/23 at 10:30 am, it was observed the two exit doors in the 64 cottage, used by residents to access the outdoor courtyard, did not have an alarm or other system to alert staff when a resident exited the unit.

In an interview on 01/30/23, Staff 4 (Facility Maintenance) acknowledged the deficiency with the door alarms. Staff 4 stated he would attempt to connect the doors to the same alert system as the call lights in resident rooms (which light up and beep loudly at a control panel monitored by staff).

In a subsequent interview on 01/31/23, Staff 4 stated he had been unable to connect the door alarms to the existing system.

On 02/01/23 the need to ensure the facility provided an exit door alarm or other acceptable system to alert staff when residents exited the RCF was discussed with Staff 1 (Administrator), and Staff 3 (LPN). They acknowledged the findings and stated the issue would be corrected by the alarm company the following day.

Since survey's environmental tour on 1/30/23, this facility has already updated the alarm system to include door alarms on house 64's two side exit doors. Updates to exit alarms were completed on 2/3/2023.