Print Inspection: CMYG

The findings of the re-licensure survey conducted 04/16/24 through 04/19/24 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.

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 04/19/24, conducted 07/02/24, 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 interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#2) whose new move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 02/2024 with diagnoses including chronic heart failure and protein-calorie malnutrition.

A review of Resident 2's move-in evaluation, dated 02/16/24, identified the facility failed to address the following required elements:

* Customary routines including bathing;

* Mental health issues including history of treatment;

* Communication and sensory including ability to understand;

* Fluid preferences;

* Fall risk or history; and

* Unsuccessful placements.

The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator), Staff 2 (Assistant), and Staff 3 (Consulting RN) on 04/19/24. They acknowledged the findings.

1. It is our policy to ensure the move in evaluation addresses all the required elements, as stated in the QAR-411-054-0034. Resident 2's move in evaluation was reviewed and updated by our facility RN. All the missing elements (customary routines, mental health issues including history of treatment, communication and sensory including ability to undertsand, fluid preferences, fall risk or history, and unsuccessful placements) were addressed, as per our policy.   Resident move in evaluations will be reviewed, and all the missing elements will be addressed for our recently moved in residents, to ensure completion. Our RN was educated on the importance of comprehensively addressing all areas in the evaluation form, and not leave any areas blank, even if some areas might not neccessarly apply to the resident evaluated.

2. Moving forward, the facility RN will make sure all the required elements, including: customary routines, mental issues/history of treatment, communication and memory/ability to understand, fluid preferences, fall risk or history, unsuccessful placement, will be addressed.

3. The area needing correction will be evaluated with every new patient admission, every new move in, and re-evaluated quarterly.

4. The professional responsible for completion and monitorization of this correction is the facility RN

Based on observation, interview, and record review, it was determined the facility failed to ensure a minimum of two direct care staff were scheduled and available at all times whenever a resident required the assistance of two direct care staff for scheduled and unscheduled needs. Findings include but are not limited to:

The facility was home to 12 residents at the time of the re-licensure survey.

During the acuity interview on 04/16/24, and observations on 04/17/24 and 04/18/24, it was noted the majority of the residents had high ADL care needs including six residents who required the use of a mechanical lift for transfers.

The facility's posted staffing plan and staff schedule were reviewed and revealed the following discrepancy:

The facility's staffing plan identified only one caregiver was scheduled for the overnight shift (7:00 pm - 7:00 am).

In an interview with Staff 1 (Administrator) on 04/17/24 at 4:00 pm, she acknowledged two direct care staff were not scheduled on the overnight shift to account for the six residents requiring the assistance of two direct care staff for mechanical lift transfers. Staff 1 stated one CG on the overnight shift could operate the mechanical lift for transfers for the six residents.

In an interview on 04/18/24 at 8:30 am, Staff 6 (CG) stated she would not feel safe operating a mechanical lift alone.

On 04/18/24 at 8:55 am, the surveyor observed a transfer of an unsampled resident who required a mechanical lift. Two caregivers were present to operate the mechanical lift and assist the resident. It was observed the mechanical lift transfer required two staff for safety and security.

On 4/18/24 at 11:12 am, the surveyors met with Staff 1 and stated the facility must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.

On 04/18/24 at 11:40 am, Staff 1 presented the surveyors a signed written statement that a second CG would be added to the overnight shift and they would start the evening of 04/18/24.

1.To correct the rule violation, a second night shift direct care staff member has been added on to the schedule, effective immediately. This is to ensure a minimum of two direct care staff members are scheduled and available at all times, whenever a resident requires assistance with scheduled and unscheduled needs and to ensure residents and staff safety.

2. Golden Age Living will add a second night shift direct care staff member at all times when a resident requires two person assistance for scheduled and unscheduled needs.

3. The above change will be evaluated quarterly, with each new resident move in, and as needed with changes in residents' condition

4. Our administrator is responsible to ensure the correction is completed and monitored

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:  

On 04/18/24 at 9:50 am, Staff 2 (Assistant) was asked to provide information on the facility's ABST. She stated the facility implemented the Oregon Department of Human Services' ABST on 04/16/24, during the re-licensure survey. Staff 2 went on to say the facility previously used a facility created paper system to document the acuity needs of the residents. The paper system was reviewed and failed to include all required 22 ADLs for each resident.

The need to implement an ABST that met regulation was discussed with Staff 1 (Administrator) and Staff 2 on 04/19/24. They acknowledged the findings.

1. To correct this rule violation our facility will be using the ABST tool provided by the Long Term Care Facility Portal. This is to ensure Golden Age Living has the adequate number of direct care staff members available to safely meet the scheduled and unscheduled needs of our residents.

2. As required by the regulations, the ABST tool will be updated with every new resident move in, change in residents' condition and quarterly.

3. An evaluation will be done with each new resident move in, change in resident condition, and quarterly.

4. The person responsible to ensure the correction is completed and monitored is the facility RN.

Based on observation and interview, it was determined the facility failed to ensure resident-use corridors had handrails installed at one or both sides. Findings include, but are not limited to:

The interior of the building was toured on 04/16/24. The corridor from the main living room and dining area to resident room 12 was observed to be without a handrail on at least one side. On 04/18/24, Staff 2 (Assistant) confirmed the resident residing in room 12 was ambulatory and relied on the use of a walker for ambulation.

The need to ensure handrails were installed along resident-use corridors was discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Consulting RN) on 04/19/24. They acknowledged the findings.

1. To correct the rule violation a handrail was installed in the small corridor that connects the main living and dining area to resident room 11 (correction states 12, but it is 11).

2. To ensure this violation does not happen again, a tour of the facility will be done annually by the administrator. During the annual tour/inspection of the facility the administrator will observe that the hand rails are properly installed in all the necessary places, and in good condition, to ensure the safety of our residents.

3. We will be performing the tour/inspection of the handrails annually.

4. The person responsible for monitoring and ensuring the handrails are properly intalled in all the right places, and are in good condition is the administrator.

Based on observation and interview, it was determined the facility failed to ensure interior surfaces and equipment necessary for the health, safety, and comfort of residents were kept clean and in good repair. Findings include, but are not limited to:

The interior of the building was toured on 04/16/24 through 04/19/24. The following areas were observed to need cleaning and/or repair:

* Multiple ceiling lights throughout the facility's corridors were burned out;

* The ceiling lighting fixture near Room 5 was cracked; and

* Multiple skylights in the main resident corridor had visible cobwebs, dirt and debris.

The areas in need of cleaning and/or repair were shown to Staff 2 (Assistant) on 04/18/24 and were then discussed with Staff 1 (Administrator), Staff 2, and Staff 3 (Consulting RN) on 04/19/24. They acknowledged the findings.

1. To correct the rule violation all ceiling lights and lighting fixtures will be replaced with LED lights by a licensed electrician. The skylights have already been cleaned.

2. To prevent this violation from happening again, the lighting system will be checked quarterly by our facility maintanance person, whom will replace the burned out lights, as needed, to ensure all ceiling lights are always in good working condition. The skylights will be cleaned monthly.

3. The administrator will be checking the ceiling lights and skylights quarterly. All staff members were educated to report any areas where burned out lights are seen, or any other malfunctioning of the ceiling lights.

4. The person responsible for monitoring and ensuring completion is the administrator.    

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters and associated heating elements did not exceed 120 degrees Fahrenheit when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

During a tour of the facility on 04/16/24, wall heaters were visualized in the bedroom of resident room 13 and in the bathrooms of resident room 2 and 4.

The heaters were turned on and the surface temperatures were recorded by the surveyor. The unit's surface temperatures ranged from 168 to 300 degrees Fahrenheit.

The need to ensure wall heater covers did not exceed 120 degrees Fahrenheit was discussed with Staff 1 (Administrator) on 04/16/24 at 4:10 pm and then again with Staff 1, Staff 2 (Assistant), and Staff 3 (Consulting RN) on 04/19/24. They acknowledged the findings. On 04/19/24, the heaters were visualized to be inoperable.

1. To correct the rule violation, all wall heaters were disabled on 4/18/24. The two bathroom heaters were permanently disabled. The bedroom heater will be replaced with a "split system heat pump" that complies with the building codes, so the ventilation unit will not be directly accessible to the residents.

2. To avoid this violation from happening again, the wall heaters are not to ever be used again in our building.

3.  To ensure the heating and cooling system are functioning properly, and to ensure the safety of our residents, staff and the building, the heating and cooling system will be serviced annually.

4. The administrator will be responsible to ensure the above is properly monitored and completed.  

Concerns were identified and the facility was provided with technical assistance in the following areas:

H 1510: OAR411-004-0020 (1)(c): Individual Rights Settings: Privacy, Dignity.

(1) Residential and non-residential HCB settings must have all of the following qualities: (c) The setting ensures individual rights of privacy, dignity, respect, and freedom from coercion and restraint.

Concerns were identified and the facility was provided with technical assistance in the following areas:

H 1518: OAR 411-004-0020(2)(e): Individual Door Locks: Key Access.

(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

According to CMS, each resident must be given a room key. If the individual cannot use it, the key can be stored in their room or given to a family member. The provider should update the resident's care plan with the details of the situation.