Print Inspection: 4Y7H

The findings of the re-licensure survey conducted 01/19/22 through 01/20/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care, 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 first revisit to the re-licensure survey of  01/20/22 conducted 02/09/22 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.

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

Meals were prepared and transported from the main kitchen located on the independent living floor to the residential care on the second floor.

On 01/19/22, the main kitchen was toured with Staff 3 (Dietary Manager) at approximately 9:45 am. The following areas were observed with splatters, spills, and debris:

* The hand washing sink;

* The handles and interior of the reach in refrigerators in the front of the kitchen. There was uncovered food in the reach in refrigerators;

* The doors, handles, and interiors of multiple reach in freezers in the baking area. There was open food packages and uncovered foods in the freezers;

* The lids of the white food storage bins in the baking area;

* The stand mixers in the baking area;

* The blades and cages of the table fan in the baking area;

* The interior of the ovens and convection oven;

* The rolling tray racks and carts throughout the kitchen; and

* The flooring throughout, including dishwashing area, had a build up of black material in the grout, around shelving legs, and in corners.

The following areas were noted to be in need of repair:

* The shelf holding the fan in the baking area was missing a strip of laminate creating an uncleanable surface;

* There was a hole in the wall to the left of the hand washing sink;

* A strip of laminate was missing from the orange counter behind the hand washing sink creating an uncleanable surface;

* The walk in freezer door was not sealing, causing frost build up on the door; and

* The bottom shelf in the coffee bar area was missing a piece of laminate creating an uncleanable surface.

The areas in need of cleaning and repair were reviewed with Staff 1 (Executive Director) and Staff 3 on 01/19/22. They acknowledged the areas needing cleaning and repair.

Cleaning

1) Sink cleaned, reach-in handles and interior cleaned, Food in daily reach-in is now covered individually, Door handles and interiors of reach-in freezers were cleaned, Food in the daily use reach-in freezers is now individually covered, White storage bin lids cleaned, stand-up mixer cleaned, Fan removed from kitchen, ovens cleaned, rolling racks and carts cleaned, and floor, corners, and shelving legs have been scrubbed and cleaned to remove black material.

2) Our survey results were shared by our Executive Director with our independent residents on 1/24/22 at the Residents Advisory meeting. They are very aware of what staffing has been like here and across our country during this pandamic. They volunteered to skip their weekly housekeeping weekly in their apartments to every other week to allow additional staffing and housekeeping hours of housekeeping / cleaning services in the kitchen. This will ensure that we have the staff to keep up with needed cleaning. A Dietary Assistant has also been hired to help in assuring cleaning is being done. Two new policies were written to address that all items in the daily use freezer and reach-in will be individually wrapped and training given. Survey results were shared with staff and they were involved with this plan of correction. The night Janitor has been trained on the floor care to ensure that he isdoing it correctly for better floor care.

3) Daily, weekly, and monthly.

4) Dietary Supervisor, Diteary Assistant, Maintenance Supervisor, Housekeeping Supervisor, and Executive Director.

Repairs:

1)  The shelf holding the fan in the baker area has been removed. 1/27/22

* The hole in the wall has been repaired 1/22/22

* Orange counter laminate has been repaired. 1/27/22

* Walk-in freezer door not sealing, Maintenance replaced the section of missing rubber seal 1/20/22

* Bottom shelf coffee bar missing laminate has been repaired. 1/27/22

2) Maintenance Supervisor will now do walk through monthly, work orders will be available in the dietary department, and Dietary Supervisor and Dietary Assistant will assist in communicating needed repairs.

3) Daily, weekly, and Monthly.

4) Dietary Supervisor, Dietary Assistant, Maintenance Supervisor, and Executive Director.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 06/2021 and was receiving hospice services.

Resident 2 had hospice orders for:

* Trazodone 50 mg once nightly as needed for sleep;

* Oxycodone 5 mg up to four times daily for pain; and

* Lorazepam 1 mg every two hours as needed for anxiety.

Resident 2's MARs, reviewed from 01/01/22 - 01/19/22, revealed the following inaccuracies:

* Trazodone was initialed as administered on the front of the MAR on 01/15/22 and 01/18/22. There was no documentation on the back of the MAR indicating the medication was given or it's effectiveness.

* Oxycodone was initialed as administered on the front of the MAR on multiple occasions when there was no documentation on the back of the MAR indicating the medication was given or it's effectiveness.

* Lorazepam was initialed as administered on the front of the MAR on multiple occasions when there was no documentation on the back of the MAR indicating the medication was given or it's effectiveness.

The narcotic records were reviewed and found accurate.

The inaccuracies were reviewed with Staff 1 (Executive Director) and Staff 2 (RN) on 01/20/22. They acknowledged the findings.

1. Inservice provided to all nurses on proper medication administration and counseling provided that disciplinary will occur if not properly done.

2. Weekly audits done by Administrator with training and or disciplinary action occuring to correct as needed.  

3Daily, weekly and monthly.

4. Charge Nurse, Director of Health Services, RCF Administrator, RCF Office assistant.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 6 and 7) completed required pre-service orientation and dementia training prior to beginning their job responsibilities and providing care for residents. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 01/20/22 and revealed the following:

1. There was no documented evidence Staff 6 (CG), hired 11/04/21, completed orientation for abuse reporting requirements, standard precautions for infection control, and fire safety and emergency procedures.

2. There was no documented evidence Staff 6 (CG) or Staff 7 (CG), hired 12/28/21, completed the required pre-service dementia training prior to providing care to residents.

The need for staff to complete all required pre-service orientation and dementia training before beginning their job responsibilities and providing care to residents was discussed with Staff 1 on 01/20/22. She acknowledged the findings.

1. Abuse Prevention and Reporting form updated for new hires.  Values of CBC form created

New form created to document training needed before providing paitent care.

2. All hired caregivers will watch approved 6 hour course on Alzheimers and Dementia training provided by Oregon Care Partners prior to working and receive training in Abuse reporting, values of CBC care, fire and safety , emergency proceedures, residents rights, and Unervsal precautions.

Audit of training for Alzheimers/Dementia, abuse reporting,resident rights, value of community based care, standard precautions for infection and fire safety and emergency procedures will be audited to ensure completion as part of our quality assurance monthly.  

3: At hire and monthly.

4. RCF Administrator and RCF Office Assistant  

Based on interview and record review, it was determined the facility failed to verify 2 of 2 newly hired staff (#s 6 and 8) demonstrated satisfactory performance in all assigned job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 01/20/22.

There was no documented evidence Staff 6 (CG), hired 11/04/21, or Staff 8 (CG), hired 03/09/21, had demonstrated competency in one or more of the following required areas:

* Role of service plans in providing individualized care;

* 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 facility's failure to ensure newly hired staff had demonstrated competency in all assigned duties within 30 days of hire was discussed with Staff 1 on 01/20/22. She acknowledged the findings.

1. New form created with required topics. Staff in question have completed training and completed this form. New hires will complete this form and training.

Inservice completed with Nurses to ensure they understand how to complete it.

2. New form added. Supervisor will observe within the 30 days. Audit of file will be conducted to ensure it is completed.

3. Monthly Will be part of our monthly quality assurance.

4. RCF Administrator  

Based on interview and record review, it was determined the facility failed to ensure long-term staff completed the required minimum 12 hours of in-service training annually for 1 of 2 long-term staff (# 9) whose training records were reviewed. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Executive Director) on 01/20/22.

There was no documented evidence Staff 9 (CG), hired 07/21/17, had completed a minimum of 12 hours of annual in-service training related to the provision of care, at least six of which needed to relate to dementia care.

The need to ensure all required in-service training hours were completed annually was reviewed with Staff 1. She acknowledged the findings.

1. Staff are in the process of being inserviced on new training program and its documents to ensure that required topics and hours are being completed appropriate to job duties.

2. Numerical based inservice created for caregivers to complete starting first month of hire. Inservices will be provided on DVD or Oregon Care Partners.  

3 Monthly

4. RCF Adminitrator and RCF Office Assistant.