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The findings of the re-licensure survey, conducted 08/08/22 through 08/10/22, 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

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 re-visit to the re-licensure survey of 08/10/22, conducted 11/17/22, 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. It was determined the facility was in substantial compliance.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had changes of condition were evaluated, resident-specific instructions or interventions were developed and communicated with staff and the condition was monitored for 1 of 1 sampled resident (# 1) who experienced short-term changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia.

Resident 1's 07/12/22 service plan, 05/06/22 through 08/08/22 Progress Notes, and temporary service plans were reviewed. The resident experienced short-term changes without documented monitoring at least weekly until resolution in the following areas:

* UTI;

* New medication; and

* Changes in eating habits related to depression.

The need to ensure changes of condition were evaluated, had documentation to reflect monitoring to resolution at least weekly, and provided clear resident-specific directions to staff, was discussed with Staff 1 (Administrator) on 08/09/22. She acknowledged the findings.

C270 OAR 411-054-0040 (1-2) Change of Condition and Monitoring.

POC C270 Resident #1 care plan was updated and rewritten to include changes regarding their food intake to monitor for depression. Additionally, TSP was put into place on 8/8/22 to address new medication, UTI symptoms, and depression. All care plans have been reviewed to ensure that the care plan is resident centered.  

Systems in place are correctly working regarding staff, and their response to change of condition, and how they communicate the changes to the Assistant Administrator.

Administrator or Designee will check that all documents for any change of condition and alert charting are accurate on a daily basis.  Staff have been educated to alert Administrator, Designee or LN of any changes that have been observed.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were added to the service plan and communicated to staff for 1 of 1 sampled resident (# 2) who was receiving home health services from outside providers. Findings include, but are not limited to:

Resident 2 was admitted to the facility in 11/2021 and had diagnoses including fall risk.

A Home Health PT left a note on 08/01/22 recommending Resident 2 perform a list of exercises to maintain lower extremity strength. There was no documented evidence a temporary service plan was written or his/her service plan was updated to provide clear instruction to staff to follow the exercise routine. An interview with Staff 1 (Administrator) revealed she did not create a temporary service plan or update the service plan to provide instruction to staff about the exercise routine.

The need to ensure the facility coordinated care with outside providers and ensure recommendations were added to the service plan and communicated to staff was discussed with Staff 1 on 08/09/22. She acknowledged the findings.

C290 OAR 411-054-0045 (2) Res Hlth Srvc: On- and Off-Site Health Services

Activities of Daily Living regarding the verbal order from  PT for walking and the daily exercises for resident # 2 were added to the care plan. Clear instruction has been given to staff to follow the exercise routine.

Facility will coordinate care with outside providers and ensure recommendations are added to the service plan and that staff are communicated with.  

The Administrator and the Assistant Administrator on duty will review the coordination of care communication notes to ensure that what is written is correct and that if any verbal orders were given, those verbal orders transpire onto the clinicians' notes. It will then be given to the Assistant Administrator or the Administrator, depending on who received the order first, for a double check that it was entered into the progress notes, if needed, added into the daily charting. It is then added to the nurses' communications binder. They are to check for accuracy in entering the information into the progress notes and, if needed, into the daily charting during their visit to the facility.       

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregiving staff to meet the 24-hour scheduled and unscheduled needs of residents to compensate for staff duties beyond direct resident care. Findings include, but are not limited to:

Observations, interviews and record review, during the survey revealed the following:

* The facility used Universal Workers, whose job duties included passing medications, providing care and services to residents, housekeeping, laundry, cooking and activities.

* Review of the staffing schedule and an interview with Staff 1 (Administrator) during the survey revealed the facility had one staff scheduled at a time during all shifts.

The need to increase staffing levels to compensate for increased staff duties and unscheduled resident needs was discussed with Staff 1 on 08/08/22. She acknowledged the need for increased staff.

C360   OAR 411-054-0070 (1) Staffing Requirements and Training : Staffing

Staffing is being addressed with a focus on hiring new staff. Additional education is being provided for the new ABST tool on how to deterimine staff labor hours and on completing the staff schedule accordingly.

The schedule was immediately updated on 08/10/2022, for 2 staff on day shift, 2 staff on swing shift and one staff on NOC shift. The schedule was adjusted on 08/10/2022, per the recommendation of the state surveyor. Staffing is being adhered to, to the best of facilities ability, as the current number of employees allows. Current staff are scheduled to cover hours, and additional staff members are being hired.

The system is working, Administrator is doing their due diligence to find qualified applicants and get them through the hiring and training process promptly. Regional Director of Operations to monitor processes for hiring potential staff. The Administrator is to keep track of the ABST tool hours required for the staffing and current resident care levels.  

Based on interview and record review, it was determined the facility failed to ensure all pre-service orientation, including food handler's certificate, and pre-service dementia training was completed prior to beginning job responsibilities, including meal preparation, for 1 of 1 newly hired staff (# 6) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/10/22.

There was no documented evidence Staff 6 (Universal Worker), hired on 05/24/22, completed the following elements of pre-service orientation:

* Resident rights and values of CBC care;

* Abuse reporting requirements;

* Infectious disease prevention;

* Fire safety and emergency procedures;

* Food handler's certificate; and

* Written job description.

The need to ensure all newly hired staff complete pre-service training before providing direct care to residents was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 08/10/22. They acknowledged the findings.

C370 OAR 411-054-0070 (3-4). Staffing requirements and Training: Caregiver requirements.

When sharing employees between facilities, there must be two complete, separate employee files at each facility. There is increased communication between administrators of the facilities to ensure that when training is completed for one, it is put into the file in both facilities.

Any employee that currently does not have any pre-service orientations or training done has been pulled from the floor and given a deadline of 10/08/2022 to complete them; if they haven't, they will be pulled from the floor and taken off the schedule until completed. Their employee files have been updated if they have already completed their pre-service training.

Employee #6, was scheduled immediately to do their on floor competencies. If employee #6 does not complete the scheduled training by 10/8/2022, employee #6 will be removed from working on the floor.

Administrators independent to each facility to double check that all employees' files are completed and within compliance. The files are already required to be audited once a month to ensure that all training are not expired as well as CPR, pre-services and food handlers cards. Once a month the Administrator for Arrowhead will be looking in current OARs to ensure that we have the most up-to-date training schedules and compliance standards to ensure that all employees are up to date on their training

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly hired staff (# 6) demonstrated competency in all required areas within 30 days of hire. Findings include, but are not limited to:

Review of the facility's training records on 08/10/22 indicated the following:

There was no documented evidence Staff 6 (Universal Worker), hired on 05/24/22, demonstrated competency within 30 days of hire in the following areas:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation and reporting changes of condition;

* Conditions that require assessment, treatment, observations and reporting;

* General food safety, serving and sanitation;

* Other duties as applicable (med pass); and

* First Aid/abdominal thrust.

The need to document demonstrated competency in all required areas within 30-days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 08/10/22. They acknowledged the findings.

C372 OAR 411-054-0070 training within 30 days:

Direct Care Staff

All employees that currently do not have any pre-service orientations, competencies, or training done have been pulled from the floor or their duties placed on the scheduled in training to complete the competencies and pre-services.

New Hire files have been completed with all the appropriate forms to be filled out as the new hires move through the training requirements.

Employee #6, was scheduled to complete all training and to demonstrate competency. If employee #6 fails to attend scheduled training promptly #6, will be removed from the floor.

Administrator and Designee will double-check that all employees' files are completed and in compliance. The files are already required to be audited once a month to ensure that all training are not expired as well as CPR, pre-services and food handlers cards. Additionally, once a month Administrator and Designee for Arrowhead will look in current OARs to ensure that we have the most up-to-date training schedules and compliance paperwork.     

Based on interview and record review, it was determined the facility failed to document a minimum of 12 hours of annual in-service training, including at least 6 hours related to dementia care, was completed for 1 of 1 long-term staff (# 3) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed on 08/10/22.

There was no documented evidence Staff 3 (Universal Worker), hired 06/03/21, had completed at least 12 hours of annual training, to include at least six hours of training related to dementia care.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Administrator) and Staff 2 (Regional Director) on 08/10/22. They acknowledged the findings.

C374 OAR 411-054-0070

Staff member #3, will complete all annual training as required. The Administrator and the Designee will audit all other employees to ensure that training is current and in compliance.

The facility Administrator and Designee will implement a training grid with all training requirements to ensure compliance.

The facility Administrator and Designee will audit the training grid once a month new hires are not able to work the floor without all certificates and that will be monitored during their training period. All exisisting employees who are out of compliance with training will be scheduled to complete training, and pulled from working the floor.        

Based on observation and interview, it was determined the facility failed to ensure courtyard pathway edges did not have drop-offs. Findings include, but are not limited to:

Observations of the exterior of the facility on 08/08/22 showed drop-offs along pathway edges in excess of two inches in multiple areas.

The need to ensure pathways in the resident courtyard did not have drop-offs was discussed with Staff 1 (Administrator) on 08/08/22. She acknowledged the findings.

C510 OAR 411-054-0200 (3) General Building Exterior

The courtyard pathway edges with drop-offs in excess of two inches in multiple areas will be filled in by adding the appropriate amount of bark mulch.    

Facility maintenance employee has been called, and an order has been put in as of 8/9/22 for bark chips to be placed within the backyard along the edge of the concrete to ensure a level field between the concrete and bark chips.

Administrator and/or Assistant Administrator once a month to ensure that bark chips are still level with concrete and to notify landscaping and Regional Director of Operations if the level has gone down.