Print Inspection: DKIQ

The findings of the re-licensure survey, conducted 10/24/23 through 10/26/23, 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 10/26/23, conducted 02/14/24, 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 second re-visit to the re-licensure survey of 10/26/23, conducted 05/10/24, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure required postings were posted in a routinely accessible and conspicuous location to residents and visitors and available for inspection at all times. Findings include, but are not limited to:

The facility was toured on 10/24/23 at 10:30 am. The following items were not posted as required:

* The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility;

* The current facility staffing plan; and

* A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.

The need to ensure all required items were posted was reviewed with Staff 1 (Administrator) and Staff 3 (Maintenance Manager) on 10/26/23. Staff 1 acknowledged the items were not posted as required.

1. The following will be posted:

(a) Facility license.

(b) The name of the administrator or

designee in charge. The designee in

charge must be posted by shift or

whenever the administrator is out of the

facility.

(c) The current facility staffing plan.

(d) A copy of the most recent

re-licensure survey, including all revisits

2. An audit will occur on a monthly basis to ensure all required postings are up and visible. A report will be sent to the Administrator with audit findings.

3. Monthly

4. Administrator

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

Resident 1 was admitted to the facility in 07/2023 with diagnoses including chronic kidney disease and mild cognitive impairment.

Resident 1's initial move-in evaluation lacked information regarding the following elements:

* Customary eating routine;

* Cultural preferences and traditions;

* Effective non-drug interventions in regards to mental health issues;

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

* How the person expresses pain or discomfort;

* Nutritional habits and fluid preferences;

* History of dehydration;

* Emergency evacuation ability; and

* Unsuccessful prior placements.

The need to ensure evaluations included all required information was reviewed with Staff 1 (Administrator) and Staff 2 (RN Manager) on 10/25/23. They acknowledged the findings.

1. The following items will be added to our evaluation process:

* Customary eating routine

* Cultural preferences and traditions

* Effective non-drug interventions in

regards to mental health issues

* Personality, including how the person

copes with change or challenging

situations

* How the person expresses pain or

discomfort

* Nutritional habits and fluid preferences

* History of dehydration

* Emergency evacuation ability

and

* Unsuccessful prior placements.

2. We have requested our EHR vendor to include the above items on our evaluation. Training to Nurse Mangers will be completed to ensure all required items are included in evaluation moving forward.

Audit will occur to ensure all evalution items are complete for current resident and part of their careplan.

3. Quarterly audits will be completed as part of our quality assurance program.

4.  Quality Assurance Manger and Administrator. .

Based on interview and record review, it was determined the facility failed to conduct fire drills according to Oregon Fire Code (OFC) and failed to keep a complete fire drill record. Findings include, but are not limited to:

Fire drill records were reviewed on 10/25/23. The following deficiencies were identified:

a. Fire drills conducted on 04/19/23 and 06/27/23 did not require the residents to participate in the drill. Additionally, the fire drill records lacked documentation of the following information:

* 04/19/23: Number of occupants evacuated.

* 06/27/23: Location of simulated fire origin, escape route used, number of occupants evacuated and problems encountered and comments relating to residents who resisted or failed to participate in the drills.

b. The facility conducted a full building evacuation (called a "Code Black") on 09/21/23. The fire drill record lacked documentation of the following information:

* Location of simulated fire origin;

* Escape route used; and

* Number of occupants evacuated (the form indicated "all").

c. The facility was not relocating residents and due to the lack of documentation, it was unclear as to whether alternate exit routes were used during fire drills to react to varying potential fire origin points.

The need to ensure fire drills were conducted and documented as required was reviewed with Staff 1 (Administrator) and Staff 4 (Safety Manager) on 10/26/23. They acknowledged the deficiencies.

1. Required employee and resident training documents will be reviewed and updated to include needed instructions and documentation per OAR.

2. Drill and training will be completed by Building Services Team (Monthly) and by Nurse Mangers at care conferences quarterly. Signed acknowledgment of traninig will be placed in resident record.

3. Monthly, quarterly and annually depending on specific requirement.

4. Administrator and Nurse Manager

Based on observation and interview, it was determined the facility failed to ensure its relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:

Refer to C630.

Refer to C630.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used when washing soiled linens and soiled clothing. Findings include, but are not limited to:

The facility was toured on 10/24/23 at 10:30 am. Each resident apartment had its own washer and dryer. Additionally, there was a room on the second and third floors that contained a hopper sink and a separate room, also on the second and third floors, containing multiple residential-type washers and dryers. None of the washers had a hot water rinse setting option. No chemical disinfectant products were observed in the hopper or laundry rooms.

In an interview on 10/25/23, Staff 7 (MT) stated that when she discovered soiled linens or clothing, she bagged the items, rinsed them as needed in one of the hopper sinks and then either washed the items in the laundry room or in the resident's apartment washer, depending on the size of the load. She stated staff used the resident's personal laundry detergent. She did not indicate the facility utilized a chemical disinfectant and stated the residents were not required to provide a disinfectant, though a few resident's had some type of a spray she could use on any stains prior to the wash.

In an interview on 10/26/23, Staff 8 (CG) stated that when she discovered soiled linens or clothing, she rinsed the items in the resident's apartment sink, if needed, and washed the items in the resident's apartment washer, unless the load was too large and needed to be washed in the laundry room. She confirmed staff used the resident's laundry detergent. She did not indicate the facility utilized a chemical disinfectant.

The interviews were reviewed with Staff 1 (Administrator) and Staff 3 (Maintenance Manager) on 10/26/23. Staff 1 stated staff were supposed to bag soiled items and transport them to a separate building where the items would be laundered in a commercial washer that provided proper disinfection. She acknowledged the staff interviewed were not following proper procedures.

 1.Chemicals will be provided and accesable for cleaning soiled items.

2. Locations will be identified and training will occur now, at time of hire and annually with care team to ensure items are cleaned per the OAR.

3. Monthly QA walk to ensure chemicals are available and team is using it properly.

4. Administrator.

Based on observation and interview, it was determined the facility failed to ensure washers had a minimum rinse temperature of 140 degrees Fahrenheit (F) unless a chemical disinfectant was used when washing soiled linens and soiled clothing. This is a repeat citation. Findings include, but are not limited to:

The facility was toured on 02/14/24 at 10:30 am. Each resident apartment had its own washer and dryer. Additionally, there was a room on the second and third floors that contained a hopper sink and a separate room, also on the second and third floors, containing multiple residential-type washers and dryers. None of the washers had a hot water rinse setting option. No chemical disinfectant products were observed in the hopper or laundry rooms.

In interviews on 02/14/24, Staff  6 (MT) and Staff  7 (MT/CG) stated when they discovered soiled linens or clothing, the items were rinsed in one of the hopper sinks and then either washed in the laundry room or in the resident's apartment. Staff 6 and Staff 7 stated they used the resident's personal laundry detergent and they were unaware of laundry detergent with a chemical disinfectant in the laundry room.

In an interview on 02/14/24 at 11:35 am, Staff 1 (Administrator) confirmed the facility did not have laundry detergent with a chemical disinfectant available in the laundry rooms for staff or residents to use with soiled linens or clothing.

The need to ensure facility staff used a chemical disinfectant when washing soiled linens and clothing in a washing machine that did not have a minimum rinse temperature of 140 degrees F was reviewed with Staff 1 and Staff 2 (RN Manager) on 02/14/24. They acknowledged the findings.

1.Chemicals will be provided and accessible for cleaning soiled items.

2. Locations will be identified and training will occur now, at time of hire and annually with care team to ensure items are cleaned per the OAR. Residents who are incontinent will be identified by nurse manager and instructions for handling soiled laundry will be added to the resident's care plan. For residents who typically wash their own laundry, the facility will meet with residents in group or individually to educate them about using the facility-provided disinfecting product. Staff will be trained to provide the disinfecting product to residents for use in their own units upon the resident's request.

3. Monthly QA walk to ensure chemicals are available and team is using it properly and monthly report that chemicals have been checked and are available for care team.

4. Administrator.