Print Inspection: 80WL

The findings of the Change of Ownership Survey, conducted 01/11/22 through 01/14/22, 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 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 revisit to the re-licensure survey of  01/14/22 conducted 03/22/22 through 03/23/22, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to implement effective methods of infection control for 1 of 1 sampled resident (#1). Findings include, but are not limited to:

Observations were made during the survey to determine adherence to universal precautions.

On 1/12/22, the surveyor obtained permission and observed two CGs providing incontinent care to Resident 1. During the observation, the CGs failed to change their gloves after toileting the resident and proceeded to touch the resident's clean clothing, wheelchair, and window blinds with the same soiled gloves. Both CGs removed their gloves before exiting the resident's room.

The surveyor instructed the CGs on appropriate infection control procedures and the importance of hand hygiene when providing care to residents.

On 1/13/21, the above observations and the need to ensure universal precautions for infection control were followed was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged appropriate infection control practices were not implemented.

Facility caregivers have been provided a copy of "Healthcare facility recommendations for Standard Precautions" and "Infection Control Standard Precautions in Healthcare", both articles are provided by the World Health Organization.  The information from both articles provide detailed instructions on proper hand hygiene and use and disposal of gloves while providing resident care.  Standard precautmions are reviewed including hand washing, use of PPE and proper use of gloves.

 Infection control policies and procedures including hand washing, providing residents with proper incontinent care and use and disposal of gloves will be reviewed on a quarterly basis by the RSCs at the monthly all staff meetings.  

 The RN will make periodic (2xweekly) observations of caregivers using proper standard precautions during the incontinent care of residents.

Continued instruction, teaching and guidance will be provided in regards to infection control procedures to all med attendants and caregivers by the RN and RSCs to assure continued compliance.  

Based on observation, interview and record review, 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:

During the kitchens tours on 1/11/22, the Meals were prepared and transported from the main kitchen located in the independent living building to the assisted living building.

The assisted living kitchenette was toured at 9:35 am. The following areas were in need of cleaning or repair:

* Ice machines had a build up of debris around the inside and outside of the machine.

The main kitchen was toured at 10:12 am. The following areas were in need of cleaning or repair:

* Dry food storage door and frame had a build up of dirt and debris;

* Dry food storage walls and floors had an accumulation of debris, and perishable food items that had fallen underneath the canned food rack;

* Vitamix machine and accessories were stored on the floor under the dry food storage racks;

* Multiple freezers had food spillage or debris inside;

* Ice machine had a build up of debris around the inside and outside of the machine;

* Ceiling air vents throughout the main kitchen had an accumulation of dust and debris;

* Cooks were not checking the temperatures of the cold food items to ensure the temperature was maintained below the required 41 degrees F when served from the tray line;

* Light fixtures or bulbs were not working in the dry food storage room, room storing paper products, ceiling light fixture above oven, and light above grill; and

* A pipe in the floor, near the ice machine in main kitchen was unstable and the floor tile around the pipe was in need of repair. This rendered the floor around the pipe an un-cleanable surface.

The areas needing cleaning and repair in both kitchens were reviewed with Staff 1 (Administrator), Staff 2 (ED) and Staff  8 (Food and Beverage Director) on 1/13/22 at 9:45 am. They acknowledged the areas that needed cleaning and repair.

Dry food storage - Door and frame have been cleaned and painted.  

Dry food storage walls and floors have been cleaned .

Vitamix machine was not working it has been stored in a proper place.

Freezers have been cleaned and ceiling air vents have been cleaned.

Ice machine has been cleaned on the inside and outside.

Temperatures on cold and hot foods are being temped to ensure that proper temperatures are maintained. All light fixtures and bulbs have been fixed.

The grouting around the pipe by the ice maker has been repaired with a cleanable material.  

Weekly cleaning schedules have been updated and implemented to ensure all areas are kept clean.

 Daily Temp logs have been implemented.  F& B Mgr. will check these logs daily to ensure it is kept clean.

Maintenace Mgr. has scheduled Monthly inspections to make sure all painting and cleaning is done on a timely basis.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in October, 2021.

Resident 1's move-in evaluation was completed on 10/14/21, and failed to address the following elements:

* Personality, including how the person copes with change and challenging situations; and

* Environmental factors that impact the resident's behavior, including, but not limited to noise, lighting and room temperature.

On 1/13/22, the failure to address all required elements of the move-in evaluation was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

All move-in evaluations were updated on 11/22/2022.  These updates include a section for personality and environmental information, how the person copes with change and callenging situations as well as environmental factors that impact the residents behaviors.  

These sections will be updated quarterly and as needed.  They will be reviewed and monitored at the quarterly service plan review by the Administrator, resident, family (if applicable) and RN.  

2. Resident 1 was admitted to the facility in October 2021 with diagnoses including congestive obstructive pulmonary disease, arthritis, carpal tunnel syndrome, and spinal stenosis.

Observations, interviews and review of the current service plan, dated 11/16/21, revealed the service plan was not reflective of the resident's current status or provided clear instructions to staff, in the following areas:

* Toileting assistance needed; and

* Dressing assistance needed.

On 1/13/22, the need to ensure service plan's were reflective of the resident care needs and were being followed was discussed with Staff 1 (Administrator) and Staff 3 (RN). They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current care needs and provide clear direction regarding the delivery of services for 2 of 3 sampled residents (#s 1 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 4's service plan, dated 11/23/21, failed to reflect the residents care needs and lacked clear direction for the delivery of care and services in the following areas:

* Clear description of behaviors and anxiety, including interventions;

* Clear instructions on the use and precautions of 1/2 length side rails;

* Weight loss interventions; and

* Hospice providing bathing assistance.

The need to ensure resident service plans were reflective of current care needs and provided specific instruction to staff was discussed with Staff 1 (Administrator) and Staff 3 (RN) on 1/13/22. They acknowledged the findings.

The service plan for resident #4 was reviewed and updated to include the following:

 A description of his ongoing behaviors including interventions for behaviors provided by Hospice and the facility.

Instructions on side rail use and resident safety precautions.

Weight loss and interventions provided by Hospice and facility to slow further weight loss.

Hospice CNA role in providing services to the resident including bathing and other duties.

The service plan for #1 was reviewed and updated to include the following:

Precise instructions on how this resident is provided inconinent care, including use of good standard precations for hand hygiene and use of gloves.  Instructions on dressing and undressing assistance.

The RN and RSC will update the service plan on a quarterly and as needed basis.  The RN will review any updates needed on a select group of residents each week prior to the service plan meeting.  The Administrator will update the service plans as needed while talking with the resident and family during the service plan meetings.  

the Administer and RN will be responsible for the accuracy of the service plan.  3/15/2022

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of direct care staff to meet the 24-hour scheduled and unscheduled needs of residents who required two-person transfers. Findings include, but are not limited to:

During the entrance conference on 1/11/22, Staff 1 (Administrator) and Staff 3 (RN) reported the facility had three residents' who required two-person assist with transfers.

In an interview on 1/13/22, Staff 1 stated the facility scheduled three direct care staff, one MT, and two CGs for the day and evening shifts, and one MT was scheduled for the overnight shift. If residents required help during the night shift, staff from the Independent Living or the other Assisted living building on campus, would assist the residents. Both of which are separately licensed communities.

During a conversation with Staff 1 regarding the lack of staff to meet the residents transfer needs during the overnight shift, she agreed that more staff was needed. She immediately added an additional CG at night. She confirmed that extra staff would be available to meet the scheduled and unscheduled needs of the residents' who required two person-transfers.

On 1/13/22 at 8:20 am, Staff 1 provided a copy of the current schedule. There was an additional CG scheduled for the night shift.  

We have obtained the Exception from Warren Bird to allow our staff, who have been trained as caregivers, in the IL building to be utilized on the NOC shift at Al1 whenever they are needed to ensure that the two person transfers can be done.   

The Administrator will review with the residents, families (if applicable) and resident during quarterly service plan  updates that all of the residents needs are being met.