Print Inspection: 96FS

The findings of the re-licensure survey conducted 01/11/22 through 01/13/22 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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 01/13/2022, conducted 03/10/2022, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure resident to resident altercations were immediately reported the local SPD office for 1 of 1 sampled resident (#1) whose records were reviewed. Findings include, but are not limited to:

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

Progress notes, dated 10/13/21 through 01/11/22 were reviewed and revealed the following:

* 12/19/21 - the resident "poked the other resident" with his/her cane "several times;"

* 12/27/21 - at 2:02 pm, Resident 1 went to another resident and pinched his/her neck;

* 12/27/21 - at 7:33 pm, the resident pulled another resident's arm, which caused the other resident to lose his/her balance. The resident pulled a chair while another resident was sitting on it. Staff documented the other resident was not injured but did state s/he was "a bit scared" of Resident 1; and

* 01/07/22 - the resident "put [his/her] cane purposely down on [another resident's] foot."

There was no documented evidence the facility immediately reported the incidents to the local SPD office.

The need to ensure all physical resident to resident altercations were reported to the local SPD office was discussed with Staff 1 (Admin/President/CFO/Owner) on 01/12/22 and 01/13/22. She acknowledged the findings. The surveyor requested and received verification that the above incidents were reported to the local SPD office on 01/12/22.

C231

1. Immediate action was taken and an APS report was created to document actions by Resident #1 against other residents. Follow up with APS is ongoing.  

Further APS reports were created later for another incident involving Resident #1.

2. Harvest Homes curent abuse and requirement policy is part of the initial employment onboarding paperwork. We also do an inservice yearly on abuse. Administrator will review incidents reports daily and report incidents of possible abuse within 24 hours.

3.As each incident happens administrator will determine whether or not it is potential abuse and needs to be reported.

4. Administrator

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 3) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task and observing the staff demonstrate the task.

During the acuity interview on 01/11/22, Resident 3 was identified to be administered insulin injections by non-licensed staff.

Resident 3's MARs, reviewed from 12/01/21 through 01/11/22, revealed insulin had been given by non-licensed staff once daily.

Delegation documentation for Staff 8 (ALF Administrator), Staff 14 (MT) and Staff 15 (RCC), was reviewed on 01/12/22 and revealed the following:

* Delegation was transferred on 11/20/21 from Staff 16 (previous RN) to Staff 2 (RN).

* There was no current delegation from Staff 2 authorizing Staff 8, 14 and 15 to give insulin to Resident 3.

In an interview on 01/12/22 at 2:15 pm, the documentation was reviewed with Staff 2. Staff 2 stated she started at the facility in November 2021 and was unaware she needed to complete her own delegation of staff to administer insulin. OSBN Division 47 Rules relating to transfer of delegation was discussed with Staff 2 during the interview. The RN Surveyor informed Staff 2 that staff needed to be delegated by her to administer insulin. She acknowledged and stated she would complete the delegations.

Failure to ensure delegation was completed in accordance with OSBN Division 47 rules was reviewed with Staff 1 (Admin/President/CFO/Owner) on 01/13/22. She acknowledged the findings.

C282

1 Nurse will have all deligations completed by February 10th 2022.

2. Nurse understands the rules concerning delegations and has marked her calender to make sure this is done timely.

3. Monthly

4. Administrator

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

Fire drill and fire and life safety records from 06/29/21 to 11/30/21 were reviewed on 01/12/22.

There was no documented evidence the facility was conducting fire drills every other month.

The requirements regarding fire drills were reviewed with Staff 1 (Admin/President/CFO/Owner) on 01/13/22. She acknowledged the findings.

C420

1.The memory care fire drill schedule has been completed for 2022. A copy has been given to maintenance.

2. Administrator and maintenance will meet the first week of the month the fire drill is due and determine a date for the drill. Administrator will mark her calendar as a reminder.

3.  Fire drills are done every other month.

4. Administrator will be responsible.

Based on observation and interview, it was determined the facility failed to ensure operable windows were designed to prevent accidental falls when sill heights were lower than 36 inches and located above the first floor. Findings include, but are not limited to:

The interior of the facility was toured on 01/11/22 at 11:00 am, and revealed the following:

* A window located outside of Room 13 was observed to be open approximately 12 inches wide. Upon inspection, the window was found to lack any means of limiting how wide the window could be opened to prevent accidental falls. The height of the windowsill was 22 inches above the floor.

*Rooms 502, 503 and 509, with sills measuring 22 inches to 34 inches, were also found to lack any means of limiting how wide the window could be opened.

The need to ensure windows above the first floor were designed to prevent accidental falls was discussed with Staff 1 (Admin/President/CFO/owner) and Staff 3 (CSO/Owner) on 01/13/22. They acknowledged the findings.

C515

1. Maintenance ordered locks from amazon immediately. They arrived on the 14th and were installed.

2 Maintenance has added to the weekly surveillance checklist to make sure all window locks have not been removed and are installed properly. Staff has been educated as to the importance of window locks and informed to tell the Med Tech or Administrator if locks have been removed and are missing.

3.Weekly by building manager to make sure everything is done.

4 Administrator will review with building manager monthly.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 231, C 420 and C 515.

refer to C231,C420, and C515

Based on interview and record review, it was determined the facility failed to ensure 1 of 3 sampled newly hired staff (#5) completed all required pre-service training, 1 of 3 newly hired staff (#5) completed competency training within 30 days of hire or prior to independently providing personal care to residents, and 3 of 3 sampled direct care veteran staff (#s 9, 10 and 11) completed 16 hours of annual in-service training. Findings include, but are not limited to:  

Staff training records were reviewed with Staff 18 (Human Resources Director) on 01/12/22.

The following deficiencies were identified:

1. Staff 5 (MT), hired on 10/18/21, lacked documentation she completed pre-service training in all required areas prior to beginning performance of job duties and had documentation of demonstrated competency in all required areas within 30 days of hire.

2. Staff 9 (CG), Staff 10 (CG) and Staff 11 (MT), hired on 12/14/20, 12/10/20 and 02/16/20 respectively, lacked documentation of completing 16 hours of annual training related to provision of care in CBC which included six hours of dementia care.

The need to ensure staff completed all required training in a timely manner and prior to working independently was discussed with Staff 18 on 01/12/22 and Staff 1 (Admin/President/CFO/Owner) on 01/13/22. They acknowledged the findings.

Z155

1 Immediate action was taken and employee signed all orientation paperwork.

2. Protocol put in place to require all hires and re-hires to fill out all paperwork completely before starting their duties. A check off sheet was created and all paperwork is now in payroll company records so the onboarding is electronic. An employee can not be scheduled without completing all paperwork on payroll website. This prevents this from happening in the furture. Staff were given inservices and required to keep them up to date.

3.administrators will check monthly to make sure payroll system is working.

Staff who are lacking monthly training were given inservices and required to have them turned in by February 26th. Depending on covid situation monthly staff meetings are held to help keep inservices up to date.

4.The Administor is responsible for tracking and will review monthly to make sure inservices have been completed..

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 282.

refer to C282