Print Inspection: E4T7

The findings of the re-licensure survey, conducted 07/24/24 through 07/25/24, 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 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 re-visit to the re-licensure survey of 07/25/24, conducted on 10/16/24, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home and Community Based Services Regulations OARs 411 Division 004.

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:

Review of the current census revealed not all facility residents were entered into the ABST, multiple residents had not been reviewed or updated quarterly, and Resident 1 was not updated following a significant change in condition.

No staffing concerns were identified.

The need to ensure all residents were entered into the tool and reviewed at least quarterly, or with changes in condition, was discussed with Staff 1 (Administrator) on 07/25/24. She acknowledged the findings.

The actions taken to C361 are as follows:

Administrator and the resident RN will be attending a training by Katie Gaffney, the ABST Operations & Policy Analyst for Online Acuity Reporting and Staffing on Friday, August 2nd 2024.

Administrator and RN will enter all current residents into the ABST system, by 9/23/24.

Administrator and RN ensure that residents are reviewed at move-in, at 30 days, at any change of condition and quaterly by 9/23/24.

The system will be corrected so this violation will not occur by:

Administrator will place on the PCC schedule all quaterly Acuity Assessment reporting due dates.

Also ensure that training and to educate my nurses to this regulation, so that they report to Admin any acuity changes with residents, or change of conditions.

Correction will be evaluated weekly by the Administrator to ensure that all new and current residents with changes of conditions have been updated on the ABST system,  if no changes to report during the quarter, then quaterly reports are  completed.

The Administrator will be responsible that all changes and corrections are monitored, completed, and reported.

Facility will be incompliance by 9/23/24.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 4 and 5) demonstrated satisfactory performance in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (Administrator) and Staff 3 (Universal Worker/Kitchen Coordinator) on 07/25/24.

There was no documented evidence Staff 4 (Universal Worker), hired 04/27/24, and Staff 5 (Universal Worker), hired 06/07/24, had demonstrated competency all job duties including providing assistance with ADLs and medication pass.

The staff passing medications on 07/25/24 had documented evidence of demonstrating competence.

Staff 2 (RN) agreed to ensure Staff 4 and 5 would demonstrate competence prior to passing medications.   

The need to ensure staff had demonstrated competence in all job duties within 30 days of hire was reviewed with Staff 1 on 07/25/24. She acknowledged the findings.

The Administrator has created a detailed training check off list/spread sheet system. The check off list includes all current residents ADL's per their care plan, medication passing, housekeeping, and online course work. (Trainings will include online, in person, and self paced models)

The Administrator and RN will make sure the training check of list/spreadsheet is being tracked with each new hire, and current staff member monthly.

The spreadsheet will list the requirements, due dates, and the date of completion. The Administrator, Nurse and staff member will all sign off on this record.

This document will be filed in the employee file, and inspected each month for completion by the administrator.

The Administrator will give each staff a list of the required trainings with instructions on how to complete and the due dates.

Administrator and RN will ensure all required training will completed within the time frame allowed.

All employee training will be in compliance by 9/23/24.

Based on interview and record review, it was determined the facility failed to ensure the required 12 hours of annual in-service training, including six hours of dementia care training, was completed for 2 of 2 long-term staff (#s 6 and 7) whose training records were reviewed. Findings include, but are not limited to:

Annual in-service training records were reviewed with Staff 1 (Administrator) and Staff 3 (Universal Worker/Kitchen Coordinator) on 07/25/24.

Staff 6 (Universal Worker), hired on 08/22/22, and Staff 7 (Universal Worker), hired on 11/20/20, lacked documented evidence of a minimum of 12 hours of in-service training annually, based on hire date, on topics related to the provision of care for persons in a community-based care setting, including training on chronic diseases in the facility population, of which at least six hours were related to dementia care.

The need to ensure long-term staff completed 12 hours of annual in-service training, including six hours of dementia care training, was discussed with Staff 1 on 07/25/54. She acknowledged the findings.

The Administrator has created a detailed annual training course list of online classes that meets requirement. (Trainings will include online, in person, and self paced models) The training has a minimum of 12 hours of in-service training annually, based on hire date, and list topics related to the provision of care for persons in a CBC setting, trainings on infectious disease outbreak & control, and 6 hours of dementia related classes.

The Administrator and RN will make sure the trainings are being tracked with each new hire, and current staff member monthly to meet deadlines.

Monthly transcripts will be printed and filed in the employee file/binder, and inspected monthly for completion by the Administrator.

The Administrator will give each staff a list of the required trainings with instructions on how to complete and the due dates.

Administrator and RN will ensure all required training will completed within the time frame allowed.

All employee training will be in compliance by 9/23/24.

Based on interview and record review, it was determined the facility failed to provide documentation of fire drills being conducted every other month, and fire and life safety instruction for staff was provided on alternate months. Findings include, but are not limited to:

On 07/24/24, fire drill and fire and life safety training records from January 2024 through June 2024 were reviewed. One fire drill was documented as conducted on 05/23/24 at 10:00 am.

*There was no other documented evidence unannounced fire drills were conducted and recorded every other month at different times of the day, with residents being relocated; and

*There was no documented evidence fire and life safety instruction to staff was provided on alternate months.

On 07/25/24, the requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator). She acknowledged the findings.

The fire drill and life safety requirements were reviewed by the Administrator and the Health & Safety Coordinator with the Morrow Co Health District. Through this meeting a new plan was set forth, with a schedule for fire drills set, that include evacuation to be conducted every other month with documentation of problems encountered, comments relating to residents who resisted or failed to participate in the fire drills. It will show evacuation time period needed and number of occupants evacuated.

Residents will be trained on fire drills and or life safety on alternating months and documented in their chart.

The fire drills and life safety trainings will be scheduled by the Health & Safety Coordinator, with assistance from the Administrator.

The administrator will ensure that these are accomplished each month and that the documentation is completed and available each and every month.

From this date moving forward WCT will be incompliance by 9/23/24.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and patios were maintained in good repair. Findings include, but are not limited to:

The exterior of the facility was toured on 07/24/24. The following issue was identified as needing repaired:

* Exterior sidewalks and patios around the facility had multiple drop offs up to 4 inches, measured from the concrete to the ground. These drop-offs created potential hazards for residents.

On 07/24/24, the building's exterior was toured with Staff 1 (Administrator). She acknowledged the findings.

The exterior sidewalks and patios around facility will have gravel, decorative rock, dirt and grass planted.

Administrator and staff will report any findings on the sidewalks and patios on weekly walk abouts.

All findings that present a potentional hazzard should be reported to Administor immediately.

Administrator will be responsible to see that the corrections are monitored and completed.

Repairs to sidewalks and patios will be completed and incompliance by 9/23/24.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device to alert staff when residents exited the building. Findings include, but are not limited to:

During the survey it was revealed the exit doors failed to have an alarming device or other system to alert staff when residents exited the building.

The lack of system to alert staff when the exit doors were used was observed and discussed with Staff 1 (Administrator) on 07/24/24. She acknowledged the findings.

Exit door alarms have been purchased and will be installed on upon arrival.

Maintenance personnel will install devices and along with Administrator make sure they are working and staff are informed and aware of the new arlarms.

Day Shift RCA Staff will monitor that the alarms, upon shift arrival, each alarm will be checked arnd working by checking each door daily when opening the facility each morning.

If an alarm is not working, they will notify Administrator, and Administrator or maintenance will fix or replace alarm in a timely manner.

Door Alarm Daily Check System form will be kept on clip board in Administrator's office, and filed each month by Administrator.

Exit door alarms will be incompliance by 9/23/24