Print Inspection: 20T7

The findings of the re-licensure survey, conducted 01/10/23 through 01/13/23, 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 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 first re-visit to the re-licensure survey of 01/13/23, conducted 05/17/23 through 05/18/23, 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 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 second re-visit to the re-licensure survey of 01/13/23, conducted 07/31/23, 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 interview and record review, it was determined the facility failed to investigate resident incidents and injuries of unknown cause to rule-out abuse or report incidents to the local Seniors and People with Disability (SPD) office if abuse or suspected abuse could not be ruled out and failed to document all required areas of investigations for 1 of 1 sampled resident (# 3) who had documented injuries of unknown cause and unwitnessed falls with injury. Findings include, but are not limited to:

Resident 3 was admitted to the facility in 06/2022 with diagnoses including hypertension.

Interviews with staff and review of Resident 3's clinical records including incident reports, progress notes dated 08/30/22 through 01/04/23, skin monitoring flow sheet and service plans revealed the following:

During the acuity interview on 01/10/23, the facility stated Resident 3 had a history of frequent falls and had a recent fall that resulted in a serious injury.

a. On 08/30/22, staff documented Resident 3 was observed returning from the smoking area with an abrasion/bruise on the back of his/her head. The resident stated s/he fell and staff sent the resident to the emergency room at 10:45 pm. On 08/31/22, staff documented 20 minutes after returning from the emergency room Resident 3 was found on his/her back on the sidewalk outside, holding one of his/her legs. The resident stated "I don't know" when asked what may have caused the event.

The facility's investigation/incident report did not include information as to how the facility ruled out abuse and there was no documented evidence the investigation had been reviewed by the Administrator or reported to the local SPD office.

b. Staff documented the following injury of unknown cause in Resident 3's progress notes:

* On 11/13/22, staff documented Resident 3 was observed to have a "fresh wound size of a quarter" on the back of his/her head.

There was no documented evidence the facility investigated the injuries or reported the injuries to the local SPD office.

The need ensure injuries of unknown cause were investigated, reviewed by the Administrator and reported to the local SPD office if abuse or suspected abuse could not be ruled out was discussed with Staff 1 (ED), Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director) on 01/12/23. They acknowledged the findings and reported the required incidents to the local SPD office, per the survey team's request. Confirmation of the reports was provided prior to survey exit.

All injuries of unknown cause will be investigated and abuse or suspected abuse reported to APS, SPD, AAA, and or law enforcement.

Wellness Director or RN will interview resident and staff in an attempt to glean how injury occurred.  Wellness Director or RN will documented all findings on an incident form.  All injuries of unknown causes will be reported to appopriate agency and or law enforcement.  ED will review and sign all incident reports.  This reporting system was discussed during an all-staff meeting so that staff now understand how to report injuries, fill out first responder forms, and deliver necessary information to the Wellness Director, RN, and ED.

This reporting system will be monitored continually and any changes will be discussed with Wellness Director, RN, and ED.

ED and Wellness Director will continually monitor all injuries, incident reports, reports sent to APS and any follow-up needed for each injury.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen, on 01/10/23 at 10:30 am, revealed the following:

* Sealant/caulking material between the walls and countertops, throughout the kitchen, was cracked and/or peeling away from the wall;

* The exterior side of the stove had a buildup of dark grease spills and stains;

* The wall, located above a food prep area near the steam table, had gouges and chipped paint; and

* The doors and doorframes had areas of chipped paint which exposed the underneath wood material.

The areas in need of cleaning and repair were reviewed with Staff 6 (Dining Services Director) on 01/10/23 and with Staff 1 (ED) on 01/13/23. They acknowledged the findings.

Prep tables will be re-caulked.  Stove will be cleaned and degreased.  Walls and door frames will be prepped and painted.  

POD will clean and re-caulk around all stainless steel prep table in kitchen.  POD will prep and paint walls and door frames and install backsplash to prevent pans from scratching walls in food prep areas.  DSD will clean and degrease stove and flat top area.

POD and DSD will monitor on a monthly basis for any wear in the caulking along stainless steel tables.  DSD has set up a cleaning schedule and stove will be cleaned on a weekly basis.

Weekly cleaning schedule is currently in place.  This cleaning schedule will also be evaluated on monthly basis to ensure continued compliance.

POD and DSD will complete and monitor this area for compliance

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current status and provided clear instruction to caregiving staff and changes and entries made to the service plan were updated and initialed for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:
 

1. Resident 2 was admitted to the facility in 11/2022 with diagnoses including Multiple System Atrophy (a progressive neurodegenerative disorder.)

Observations and an interview with Resident 2 on 01/11/23, and an interview with Staff 9 (CG) on 01/10/23 revealed the service plan last updated on 12/29/22, was not reflective of his/her status and lacked clear instruction to caregiving staff in the following areas:

* Specific assistance needed with incontinence care provided in bed;

* Routine of bathing and personal hygiene needs;

* Dressing assistance specifics;

* Bed mobility;

* Dietary intake, including eating and drinking ability;  

* Dental status and oral hygiene needs; and

* Specific instructions related to evacuation assistance.  

On 01/13/23, the need to ensure service plans were reflective of the resident's needs and provided clear instruction to staff was discussed with Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director). They acknowledged the findings.   

2. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia.

Resident 1's service plan was reviewed. Multiple hand written updates were observed on the service plan and were not consistently being dated and initialed.

On 01/13/23, the need to ensure service plan changes were consistently dated and initialed was discussed with Staff 1 (ED) and Staff 4 (Wellness Director). They acknowledged the findings.

Quarterly service plans will be written in a timely manner and reflect the necessary requirement for each resident to reflect resident specific care.

Met with dietary staff to determine residents needs.  Resident's Dr. determined it was medicine related and the dosage of medicine was reduced.  New care plan was implemented with significant change.  New care plan was relayed to staff.  Staff reviewed new care plan and sign off that they understood new info.  

Staff will relay any significant changes to WD and RN.  RN and WD will evaluate and produce new care plan if needed.  Once new care plan is developed, WD and RN will review changes with care staff.  Care staff will read and sign new care plan.

Any time there is a change in condition, new care plan, or new assessment, all documentation will be evaluated.

RN and Wellness Director will be responsible for monitoring and completing any new assessments or care plans.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 2 of 3 sampled residents (#s 1 and 2) whose service plans were reviewed.  Findings include, but are not limited to:

Resident 1 and 2's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans.

On 01/13/23, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) and Staff 4 (Wellness Director). They acknowledged the findings.

Care plan meetings will take place on all residents that are in need of a 30 day assessment, quarterely assessment, or significant change of condition assessment.

Any resident that has an assessment due, RN or WD will evaluate and produce new care plan.  Once new care plan is developed, WD or ED will reach out to family to coordinate a care plan meeting.  Once care plan meeting is complete, family and ED will sign care plan. WD and RN will review changes with care staff.  Care staff will read and sign new care plan.  

Anytime there is an assessment due or a significant change of condition.

Wellness Director and RN will be responsible for monitoring and completing any new assessments or care plans.  ED and WD will be responsible for initating care plan meeting with families and ensure that staff sign new service plan

Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, monitored consistent with the residents' evaluated needs and resident specific interventions were determined, documented, and communicated to staff with weekly progress noted until the condition resolved for 3 of 3 sampled residents (#s 1, 2 and 3) who had documented changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including hypertension.

Interviews with staff and review of Resident 3's clinical records including incident reports, progress notes dated 08/30/22 through 01/04/23, skin monitoring flow sheet and service plans revealed the following:

a. During the acuity interview on 01/10/23, the facility stated Resident 3 had a history of frequent falls, some of which resulted in injuries.

* On 10/05/22, staff documented Resident 3 had an unwitnessed fall in his/her apartment. No injury was noted; and

* On 10/20/22, staff documented Resident 3 fell when reaching for his/her wheelchair in the hallway near his/her room. No injury was noted.

The facility failed to determine and document resident specific interventions related to falls or fall prevention and failed to monitor previous fall interventions consistent with his/her evaluated needs and service plan.

b. On 11/13/22, staff documented Resident 3 had a "fresh wound size of a quarter" on the back of his/her head. There was no documented evidence the facility determined what actions or interventions were needed or noted weekly progress of the wound through resolution.

The need to ensure residents who experienced changes of condition were evaluated, monitored consistent with the residents' evaluated needs and resident specific interventions were determined, documented, and communicated to staff with weekly progress noted until the condition resolved was discussed with Staff 1 (ED), Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director) on 01/12/23. They acknowledged the findings.

2. Resident 2 was admitted to the facility in 11/2022 with diagnoses including type two diabetes.

A review of Resident 2's progress notes dated 11/15/22 through 01/09/23 identified the following change of condition:

*12/18/22 - noted the resident had two loose bowel movements;

*12/24/22 - noted the resident had a large loose bowel movement;

*12/28/22 - noted the resident had a large loose bowel movement;

*12/29/22 - noted the resident had a large loose bowel movement; and

*12/31/22 - noted the resident had two large loose bowel movements.

Interviews with Staff 9 (CG) on 01/10/23 and Staff 11 (CG) on 01/12/23, indicated the resident had frequent loose bowel movements. During an interview with Resident 2 on 01/11/23, the resident reported every time s/he ate something, they had loose bowel movements.

There was no documented evidence the facility evaluated the resident, determined or documented actions or interventions needed, or monitored the change of condition through resolution.

On 01/13/23, the change of condition was reviewed and discussed with Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director). They acknowledged the findings.

3. Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia.

Interviews with staff and review of Resident 1's clinical records including incident reports, progress notes dated 10/10/22 through 01/04/23, and service plans revealed the following:

*On 12/01/22, staff documented Resident 1 experienced an unwitnessed fall with injury in their apartment. Resident 1 had a half inch skin tear on their left chin and a hematoma above the left eyebrow. There was no documented evidence the facility developed resident specific actions or interventions to minimize further falls and monitored weekly until resolution.

*On 12/22/22, staff documented Resident 1 experienced an unwitnessed fall without injury. There was no documented evidence the facility developed resident specific actions or interventions to minimize further falls.

On 01/13/23, the need to ensure residents who experienced changes of condition were evaluated, monitored consistent with the residents' evaluated needs and resident specific interventions were determined, documented, and communicated to staff with weekly progress noted until the condition resolved was discussed with Staff 1 (ED) and Staff 4 (Wellness Director). They acknowledged the findings.

Residents who experience change of condition will be evaluated and monitored with specific interventions and communicated to staff.

Staff will relay any significant change or injuries of unknown cause to WD and RN.  RN and WD will evaluate and produce new care plan if needed.  Once new care plan is developed, WD and RN will review changes with care staff.  Care staff will read and sign new care plan.

All falls will be evaluated, investigated, and reported to APS if necessary.  All falls will be recorded on an incident report and a narrative of that incident will be produced along with a different intervention for each occurance.  

Daily progress notes will be written in the chart of the resident until the issue is resolved.  These progress notes will also be shared with the care team  to ensure specific needs of the resident is met.

Wellness Director and RN will be responsible for monitoring and completing any new assessments, care plans or significant changes of conditions.

Based on observation, interview, and record review, it was determined the facility failed to ensure the RN completed a significant change of condition assessment, which included findings, developed interventions based on the condition of the resident, and updated the service plan for 1 of 1 sampled resident (#2) who experienced significant changes of condition. Findings include, but are not limited to:

During the acuity interview on 1/10/23, that facility stated Resident 2 had a recent decline and was dependent on staff for all ADL care.

Observations and interviews with Resident 2 on 01/11/23 and 01/12/23 identified the resident was not eating the meals delivered from the kitchen and the resident reported that most of his/her teeth were loose, and it was hard and painful to eat and explained when she/he ate something, "it just goes right through me."

Interviews on 01/10/23 and 01/11/23 with caregivers and a medication aide indicated the resident had recently declined and was not eating anything substantial.

In an interview on 01/12/23 with Staff 5 (Resident Services Director) explained the resident had significantly declined within the last two weeks and had a decreased appetite.

An RN significant change of condition assessment completed on 12/31/22 did not address   the resident's decline in nutritional intake and decline in dental status.

On 01/12/23, the surveyor discussed the above concerns with Staff 3 (RN Oversight). Staff 3 confirmed she had not completed a significant change of condition assessment which addressed the resident's dietary intake and dental status. Staff 3 completed a health status note later that same day which included the status of the resident, documented findings, and developed interventions related to the resident's significant change of condition. Staff 3 provided a copy of the note on 01/13/23.

The need for an RN assessment which included findings, resident status and interventions made as a result of the assessment and updating the service plan was discussed with Staff 3, Staff 4 (Wellness Director) and Staff 5 on 01/13/23. They acknowledged the findings.   

RN will complete assessments on any resident that has a significant change of condition.

Staff will relay any significant changes to RN.  RN will evaluate and produce new care plan if needed.  Once new care plan is developed, WD and RN will review changes with care staff.  Care staff will read and sign new care plan. Care plan will also be signed by Wellness Direcor and ED.

Anytime there is a significant change of condition, this will be evaluated for compliance.

RN will monitor and be responsible for all corrections and compliance.

Based on interview and record review, it was determined the facility failed to ensure an RN significant change of condition assessment was completed which included findings, resident status, and interventions for 1 of 1 sampled resident (#9). This is a repeat citation. Findings include, but are not limited to:

Resident 9 was admitted to the facility in 05/2022 with diagnoses including hypertension and spinal stenosis. A review of the resident's 03/17/23 through 05/17/23 progress notes, incident reports and investigations, and temporary service plans, as well as staff interviews, identified the following:

*On 03/17/23 the resident experienced an unwitnessed fall resulting in left ankle pain.

*The resident was sent to the emergency department on 03/21/23 due to continued swelling and tenderness in his/her left ankle.

*An x-ray of the resident's left ankle revealed a "small" fracture.

There was a progress note dated 03/21/23 by Staff 3 (Oversight RN) related to an "SCOC [significant change of condition]." The assessment did not include findings, resident status, or interventions resulting from the assessment.

In an interview on 05/18/23, Staff 3 acknowledged the change of condition assessment did not include all required information.

On 05/18/23 the need to ensure significant change of condition assessments included all required information was discussed with Staff 1 (Executive Director), Staff 3 (Oversight RN), and Staff 4 (Wellness Director). They acknowledged the findings.

a.Resident #9 had an updated RN assessment addressing current status, interventions that were implemented for the resident was done on 3/21/23 for date of Dr. visit and Fx Dx, 3/28/23 re-assessment was done and 4/4/23 the SCOC was completed.

a.Regional RN reviewed with community RN and Wellness Director the core components of a significant change of condition assessment.

b.A Significant Change of Assessment Guide  will be used as a reminder of elements to include in charting of assessment in the resident's record.

a.Incident reports will be reviewed and ensure appropriate documentation of significant change of condition is made in the resident's record for each resident.

completed/monitored?

a.The RN will ensure assessment documentation meets required elements.

b.The ED and WD will review incident reports and ensure documentation has been completed.

Based on observation, interview, and record review, it was determined the facility failed to coordinate care with outside providers in order to ensure the continuity of care for 1 of 3 sampled residents (#2) who received services from an outside provider. Findings include, but are not limited to:

During the acuity interview on 01/10/23, Resident 2 was identified to be receiving home health PT and OT services.

Observations of the resident, interviews with staff and review of outside provider notes and progress notes from 11/15/22 through 01/09/23 were completed.

In a 12/21/22 outside service coordination note, the resident's Nurse Practitioner instructed the facility to monitor oxygen saturation twice daily and to send the resident to the ER if oxygen was below 88% or the resident was having trouble breathing.

There was no documented evidence the facility had reviewed the Nurse Practitioner note. There was no evidence the instructions were implemented and or/ communicated to staff.

In an interview on 01/13/23 with Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director), indicated they were unaware of the above outside provider note and did not have information whether the resident's oxygen was monitored.

The need to ensure the facility effectively communicated outside providers instructions/recommendations to staff and ensured facility staff followed the new instructions was discussed with Staff 3, Staff 4, and Staff 5 on 01/13/23. They acknowledged the findings.

A new system will be put in place to ensure that all outside provider notes are received and reviewed.

An outside provider box has been placed outside the wellness office where all providers will place any progress notes.  The WD will review these notes and initial that action has been taken if needed.  Any outside provider notes that come by fax, now go thru a triple check system, WD initiates any action needed, and makes a progress note in the residents chart regarding that action taken.  WD will communicate any changes or actions taken to the care staff.

Anytime there is a new outside provider note either received in person or by fax

WD and RSC will be responsible for ensuring that notes are received and handled appropriately.  

Based on interview and record review, it was determined the facility failed to ensure there was a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#2) who self-administered medications. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2022 with diagnoses including Multiple System Atrophy (A progressive neurodegenerative disorder).

During the acuity interview, Resident 2 was identified as self-administering his/her medication. The facility provided a copy of the self-administration of medication assessment, completed 11/14/22, however, there was not an order from a physician indicating approval for the resident to self-administer his/her prescription medications.

The need to have a written order from a physician or other legally recognized practitioner for a resident to self-administer medications was discussed with Staff 3 (RN Oversight), Staff 4 (Wellness Director) and Staff 5 (Resident Services Director) on 01/13/23. They acknowledged the findings.

Any and all residents that are choosing to administer their own meds will have a Dr's order in place.  

The WD or RN will conduct a self-med assessment with the resident. Once that is complete, WD or RN will send assessment to Dr and ask for a written order for that resident allowing for administering their own meds.

Any time a resident wants to self administer meds, a Dr's order will be sought out.

WD, RN, or RSC will be responsible to ensure all residents that administer their own meds have a Dr's order and a self-med assessment.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions prior to the administration of a PRN psychotropic medication for 1 of 1 sampled resident (#1) who was prescribed a PRN psychotropic medication. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 08/2022 with diagnoses including dementia.

Review of Resident 1's 12/01/22 through 01/10/23 MAR showed they were given PRN Lorazepam 0.5 mg (for anxiety) on 10 separate occasions without documented evidence the facility had attempted non-drug interventions prior to administration of the medication.

On 01/13/23, the need to ensure to ensure staff documented non-pharmacological interventions were ineffective prior to administering a PRN psychotropic medication was discussed with Staff 1 (ED) and Staff 4 (Wellness Director). They acknowledged the findings.

WD or RN will conduct a training for staff in regards to psychotropic meds and non drug interventions.  WD or RN will ask provider for specific parameters if the medication is prescribed as a PRN.  WD or RN will also ask provider not to prescribe psychotropic meds as a PRN.

Any person on the care team, passing PRN psychotropic meds will attempt at least three non-drug interventions before meds will be given.  These non-drug interventions will be documented in the med book and resident chart.  If meds are given, this will be documented and the resident will be monitored for any side effects of medication. Any side effects will be reported to WD, RN, and provider.

Any instance that a resident is prescribed a psychotropic med, this will be evaulated for compliance

WD and RN will be responsible for ensuring corrections are made and the facility is in compliance.  

Based on interview and record review, it was determined the facility failed to ensure newly hired staff completed pre-service orientation in all required topics, including pre-service dementia training and infectious disease prevention training, prior to beginning job responsibilities and providing services to residents for 2 of 3 newly hired staff (#s 10 and 12). Findings include, but are not limited to:

The facility's training records were reviewed during survey and revealed the following:

* Training records for Staff 10 (CG) hired on 10/18/22, lacked documented evidence infectious disease prevention training had been completed; and

* Training records for Staff 12 (CG) hired on 12/12/22, lacked documented evidence pre-service dementia training had been completed.

The need to ensure newly hired staff completed all required pre-service training was discussed with Staff 1 (ED) and Staff 5 (Resident Services Director) on 01/13/23. They acknowledged the findings.

All staff will complete pre-service training prior to starting job responsibilities and providing care.

All newly hired staff will complete the necessary pre-service training prior to working and caring for residents.  Staff will be introduced to and will read the resident's service plans before caring for resident(s).

Newly hired staff will be assigned specific classes on Relias to satisfy the "pre-service" training.  Ongoing training will be completed on a monthly basis thru Relias computer learning program or thru topics addressed at monthly all-staff meetings.

Training is currently monitored and will continue to be monitored on a weekly basis.  Each Sunday an email is sent to department heads informing each of what training needs to be completed for their respective employees.

ED and Concierge will monitor all staff training for compliance for new and existing staff members.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired employees (#s 18 and 19) completed all required pre-service topics and pre-service dementia training prior to beginning their job duties. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 05/17/23.

1. There was no documented evidence Staff 18 (CG), hired 04/10/23, or Staff 19 (CG), hired 04/18/23, had completed one or more of the following pre-service orientation topics prior to beginning their job responsibilities:

*Resident rights and values of CBC care; and

*Infectious Disease Prevention.

2. There was no documented evidence Staff 18 or Staff 19 had completed any of the required pre-service dementia training.

The need to ensure new employees completed all required pre-service orientation and dementia training within the timelines specified in the rule was discussed with Staff 1 (Executive Director) on 05/17/23. He acknowledged the findings.

a.Staff 18 completed Infectious Disease Prevention training on 5/9/23.

b.Staff 19 completed Infectious Disease Prevention training on 5/12/23.

c.Staff 18 completed or is scheduled to complete pre-service dementia training on 6/30/23.

d.Staff 19 completed or is scheduled to complete pre-service dementia training on 6/30/23.

a.All newly hired staff will complete the necessary pre-service training, which includes the 2 hour Infection Control class offered by Oregon Care Partners, and all topics of dementia pre-service training, prior to performing direct care with residents through Relias.  

b.If pre-service training is not complete, staff will not be added to the "floor" schedule until this training is complete.  

a.Training is currently monitored and will continued to be monitored on a weekly basis.  

a.ED and Concierge will monitor all staff for training

Based on interview and record review, it was determined the facility failed to provide documentation that fire drills included all required components and staff were trained in fire and life safety on alternating months of the fire drills. Findings include, but are not limited to:

Fire and life safety records from 06/2022 through 12/2022 were reviewed during the survey. The following deficiencies were identified:

*Fire drills were not consistently being conducted every other month;
*Fire and life safety instruction was not consistently being conducting on alternating months of fire drills;

*Fire drills were not consistently documenting all required components such as escape route used and number of occupants evacuated; and

*There was no documented evidence the facility used alternate escape routes during fire drills.

During an interview on 01/12/22, Staff 2 (Plant Operations Director) reported the facility had not been evacuating or relocating residents to a designated point of safety during fire drills.

On 01/12/23, the need to ensure the facility was conducting fire drills every other month, documented all required fire drill components, were evacuating or relocating residents to the point of safety, and provided fire and life safety instruction to staff on alternating months of the fire drills was discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

Fire drill will be conducted in accordance with the state regulations

Fire drill will be conducted by POD on a monthly basis on different shifts.  Drill will be documented with date and time.  The location of the fire will be documented as well as the exit route taken.  Each fire drill will have a different escape route.  The amount of resident that participated, staff participation as well as the amount of residents evacuated will be documented on the form. At the end of the drill, staff will discuss any issues or concerns regarding evacuation route, resident safety, or general safety concerns.

Each time time there is a drill, we will evaluate the drill to address any concerns or corrections that need to be made.

POD and ED will responsible for completion or corrections.  

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

On 01/12/23, fire and life safety records were reviewed with Staff 1 (ED) and Staff 2 (Plant Operations Director).

There was no documented evidence a written record of fire safety training for residents, including content of the training sessions and the residents who were in attendance was completed, at least annually.

On 01/12/23, the need to ensure residents were instructed on fire and life safety procedures at least annually was discussed with Staff 1 and Staff 2. They acknowledged the findings.

Residents will continue to be trained upon admission about fire life safety items including fire drills and evacuation procedures.  The residents will also be re-trained on a yearly basis as refresh.

The Fire Life Safety policy for Parkland Village has been re-written to reflect that the training will happen upon admission as well as once a year.  This new policy has been approved by the Fire Marshal.  It will also reflect that residents will not "stay in place," but go to a predetermined muster point and await further instructions.

Each resident will be trained upon admission as well as once a year.

POD will continue to complete the training for new residents as well as the yearly renewal.  Fire Marshal will also come in once a year for additional training.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were properly labeled and maintained in a locked storage unit, exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents, and facility grounds were kept free of litter and refuse. Findings include, but are not limited to:

On 01/10/23, during a tour of the exterior of the facility, the following were identified:

*Exterior pathways in the courtyard and around the perimeter of the building contained multiple drop offs up to 2 inches, measured from the concrete to the ground. These drop-offs created potential fall hazards for residents;

*Multiple pesticides were observed accessible to the residents in unlocked cabinets in a resident courtyard;

*Multiple broken chairs, generators, and a power floor cleaner were observed stored in a resident courtyard;

*A refrigerator and an oven range were observed against the building at a side entrance; and

*Yard tools, concrete blocks, gas cans, and a riding lawn mower were observed against the building at the rear entrance.

On 01/10/23, the need to ensure all toxic materials were properly labeled and maintained in locked storage to avoid access by residents, all exterior pathways were maintained in good repair, and facility grounds were kept free of litter and refuse was discussed with Staff 1 (ED) and Staff 2 (Plant Operations Director). They acknowledged the findings.

All items will be removed from porches and entryways.  barkdust will be put in place by all sidewalks so that there is not a drop off.

A shed has been purchased so that all items from porch and entryways will be stowed.  Barkdust has been ordered and will be place along sidewalks so there is not a discernible drop off.  The shed has a 7-8 week lead time, however until shed is received all items on porches will be stowed.

ED will continue to walk thru and around building on a daily basis.  

ED will ensure, thru daily walks in an around builiding, that there are no drop offs by sidewalks and that all items from porches and entryways are stowed properly.

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 was in clean and in good repair. Findings include, but are not limited to:

During a tour of the facility on 01/10/23, the following was observed:

*Multiple floors throughout the facility were observed with cracks and in need of repair; and

*An accumulation of spider webs on walls and ceilings near resident entrance and exit doors.

On 01/10/23, the need to ensure all interior and exterior materials and surfaces were maintained in clean and good repair was discussed with Staff 1 (ED) and Staff 2 (Plant Operations Director). They acknowledged the findings.

Floors in the entryways that are cracked or in disrepair will be replaced.

Flooring company has contracted to replace floors in entryways that are cracked or in disrepair.  Floors will be completed by 2/28/23.  POD will walk the interior and exterior of the building and remove any excess cobwebs from building.

Daily walks are currently conducted and will continue so that any part of the building that may be in disrepair can be fixed in a timely manner.

ED and POD will responsible for continued compliance of building being clean and in good repair.