Print Inspection: EZ2V

The findings of the re-licensure survey, conducted 04/08/24 through 04/11/24, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for 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

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 revisit to the re-licensure survey of 04/11/24, conducted on 07/22/24, 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, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on interview and record review, it was determined the facility failed to ensure all required elements were addressed in the move-in evaluation and to ensure quarterly evaluations were completed for 2 of 4 sampled residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to:

1. Resident 2 moved into the facility in 02/2024 with diagnoses including multiple myeloma and diabetes mellitus.

The resident's move-in evaluation, dated 01/30/24, was reviewed during survey. The following required elements were not addressed:

* Cognition including memory, orientation and decision making;

* Transfer status;

* Dental status and assistive devices;

* Non-pharmaceutical interventions for pain and how a person expresses pain or discomfort; and

* Elopement risk and history.

The need to address all required elements in the move-in evaluation was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 3 (Regional RN) on 04/10/24. They acknowledged the findings.

2. Resident 3 moved into the facility in 09/2023 with diagnoses including dementia and Alzheimer's disease.

The most current evaluation available in the resident's chart was dated 11/06/23.

During an interview on 04/10/24 with Staff 3 (Regional RN), survey requested the most current quarterly evaluation for Resident 3. Staff 3 reported the 11/06/23 evaluation was the most current evaluation and there was no further information to provide.

The need to ensure evaluations were updated quarterly was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 on 04/10/24. They acknowledged the findings.

1. Residents 1 & 4 are no longer residents of the community. Residents 2 & 3 will have a new evaluation completed that reflect all areas required per OAR 411-054-0034.

2. All parties involved in performing pre-move in evaluations will be inserviced in the proper usage of the tool. They will also be inserviced on the quarterly evaluation requirements per OAR 411-054-0034 & OAR 411-054-0027. This inservice will be completed by 6/9/2024.

3. This area will be evaluated weekly by the Health & Wellness Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

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 (#1) 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.

Resident 1 was admitted to facility in 04/2024 with diagnoses including dementia and diabetes.

During the acuity interview on 04/08/24, Resident 1 was identified to be administered insulin injections by non-licensed staff.

Resident 1's MARs, reviewed from 04/01/24 - 04/08/24, revealed insulin had been given by Staff 10 and 16 (MTs) on multiple occasions between 04/01/24 and 04/08/24.

Review of delegation documentation on 04/08/24 revealed there was no documented delegation completed for Staff 10 and 16 until 04/05/24.

The need to ensure staff who administered insulin injections were delegated in accordance with OSBN Division 47 Rules was discussed with Staff 3 (Regional RN) on 04/08/24, and Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 04/10/24. They acknowledged the findings.

1. Resident 1 is no longer a resident of the community. All other diabetic residents requiring insulin delegation have been delegated per OAR 411-054-0045.

2. Prior to completing skills checklist for new staff members, the community RN will complete delegation for all new medication aids. For new admission residents, the community RN will delegate all staff on day of admission to ensure adherance to the rule.

3. This area will be evaluated weekly by the Health & Wellness Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on observation, interview and record review, the facility failed to ensure all medications obtained through a pharmacy was clearly labeled with the pharmacist's label and in the original container for 1 of 1 sampled resident (#2) who's medications were reviewed. Findings include, but are not limited to:

Resident 2 moved into the facility in 02/2024 with diagnoses including multiple myeloma.

The resident's MAR's dated 03/01/24 through 04/07/24, and current physician orders reviewed during the survey identified the following:

The resident was prescribed oxycodone 10 mg every four hours as needed for pain. During a narcotic count with Staff 14 (MT) on 04/09/24 at 2:30 pm the prescribed oxycodone was not in a unit dose packaging (bubble or blister pack).

Upon opening the prescription bottle the surveyor observed multiple white tablets and multiple pink tablets of a different size and shape within the same bottle. The description on the medication bottle noted the medication should be a white tablet. Staff 14 was unable to confirm what the pink tablet was or what dosage the medication was.

Survey requested the assistance of Staff 3 (Regional RN) who was able to confirm with an internet search that the pink tablet was oxycodone 10 mg. Staff 3 acknowledged the pink tablets were not in their original container with a pharmacist label. Additionally, there was no way to verify the expiration date of the medication. Staff 3 immediately removed the medication from the medication cart and contacted the resident's prescriber.

The need to ensure all medications obtained through a pharmacy were labeled with the pharmacist's label and in the original container was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 on 04/10/24. They acknowledged the findings.

1. The medication in question for Resident 2 was destroyed immediately per OAR 411-054-0055.

2. Weekly narcotic system audits will be conducted to ensure medications are packed appropriately whenever applicable, counts are accurate and true, and medications are labeled accurately.

3. This area will be evaluated weekly by the Health & Wellness Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired direct care staff (#s 7, 11 and 14) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to:

Staff training records were reviewed with Staff 1 (ED) and Staff 4 (Office Manager) on 04/10/24.

Staff 7 (CG), hired 02/06/24, Staff 11 (MT), hired on 02/29/24, and Staff 14 (MT), hired 02/24/24, lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire.      

The need to ensure direct care staff completed the required first aid and abdominal thrust training within 30 days of hire was discussed with Staff 1 and Staff 4 on 04/10/24. They acknowledged the findings.

1. All staff found deficient in pre-service training will have this completed prior to 6/1/2024 per OAR 411-054-0070.

2. All new staff will complete all pre-service required training prior to working directly with residents. This will include an approved pre-service dementia training, infection control training, first aid/CPR training, abdominal thrust training and a valid food handlers card.

3. This area will be evaluated weekly by the Office Manager.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on interview and record review, it was determined the facility failed to conduct fire drills every other month in accordance with the Oregon Fire Code (OFC) and failed to provide fire and life safety instruction to staff on alternate months. Findings include, but are not limited to:

The previous six months of fire drill and fire and life safety training records were reviewed on 04/08/24 with Staff 1 (ED). The following deficiencies were identified:

* One fire drill was conducted; however the simulated fire was conducted in the assisted living unit which is a separate licensed facility, not located within the MCC. Fire drills were not conducted in the MCC every other month, as required.

* The facility provided one fire and life safety training for staff on 03/14/24. The facility failed to provided fire and life safety training on alternate months of the fire drills, as required.

The need to ensure fire drills and fire and life safety training was conducted per the OFC was reviewed with Staff 1 on 04/08/24. She acknowledged the findings.

1. Fire drills and fire & life safety training will be conducted on alternating months to ensure proper staff training per OAR 411-054-0090.

2. A schedule outling the months in which fire drills are to be conducted and which months fire & life safety training will take place has been created and placed in the fire drill binder. Map of the community have been provided to document the escape route used during the fire drill. Copies of fire & life safety topics will be included with documentation forms as proof of topic covered. The maintenance director will be inserviced on the proper way to run and document fire drills and as well as fire & life safety training. This inservice will be completed by 6/9/2024.

3. This area will be evaluated weekly by the Maintenance Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed in fire and life safety procedures within 24 hours of admission and re-instructed at least annually. Findings include, but are not limited to:

In an interview on 04/08/24 with Staff 1 (ED), fire and life safety records were reviewed and the following was identified:

Survey requested documentation of fire and life safety instruction provided to residents within 24 hours of admission and the process for re-instruction, at least annually after admission.

Staff 1 confirmed new residents were not instructed about the facility's fire and life safety procedures and an annual written record of fire safety training, including content of the training sessions, was not being done.

On 04/08/24, the need to ensure the facility had a written record that residents were instructed in general safety procedures, evacuation methods, responsibilities during fire drills and designated meeting places outside the building or within the fire safe area in the event of an actual fire within 24 hours of admission and at least annually was discussed with Staff 1. She acknowledged the findings.

1. Fire drills and fire & life safety training will be conducted on alternating months to ensure proper staff training per OAR 411-054-0090.

2. Residents and family members will be instructed on fire procedures at move in which will include evacuation methods, what their responsibilities are and the meeting place in the event of an evacuation. This training will be repeated yearly. Both trainings will be documented in writing. This annual training will be completed by 6/9/2024.

3. This area will be evaluated weekly by the Maintenance Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:

The interior of the facility was toured on 04/08/24 and 04/09/24. The following deficiencies were identified:

* Walls and corner walls had paint chips and gouges in multiple areas throughout the facility;

* Carpet in the hallways had several dark stained areas observed;

* Several bench seats and sitting chairs in the hallways had areas of dark stains and food splatters;

* The leather couch in an alcove off the hallway by the memory care entrance door had one cushion with a large area of dried fecal matter;

* Door to Room 7 had a scraped area exposing bare wood beneath;

* Return air vents throughout the unit had a thick layer of dust;

* Vinyl flooring in the three MCC laundry rooms were observed to be worn and scratched, some areas lifted away from the wall, a long area of cracked vinyl on the floor next to the wall of the staff laundry room, and the staff laundry room and smallest resident laundry room were missing several patches of vinyl, exposing bare floor and/or wall;

* The dryer vents located on the walls just above each of the dryers in the three laundry rooms had dust and lint hanging from vents and paint peeled away from the wall areas surrounding the vents;

* The ceiling in the staff laundry room above the dryers had an area approximately 32 inches where the paint was loose, peeled back and was hanging down slightly;

* The washing machines in each of the two resident laundry rooms were reported by staff as not functioning and the dryer in the small resident laundry room did not work properly and required multiple cycles to dry one load of laundry; and

* The ceiling fan in the small resident laundry room was full of debris and staff reported did not work properly, which caused high levels of humidity in the room when the dryer was used.

The areas in need of cleaning and repair were reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 5 (Maintenance) on 04/08/23 and 04/09/24. They acknowledged the areas needing cleaning and repair.

1. The facility will repair and maintain all materials and  surfaces in good repair per OAR 411-054-0200.

2. A weekly repair schedule will be created and followed to ensure that all areas are maintained in good repair and constitue a cleanable surface at all times. Daily housekeeping will ensure that all surfaces are clean and disinfected. All carpet and furniture will be cleaned appropriately. Flooring in all laundry areas will be replaced. Dryer vents will be cleaned weekly and drywall around vents repaired and painted. The ceiling in the staff laundry room will be repaired and painted. All washing machines and dryer not functioning will be replaced. The ceiling fan in the small resident laundry room will be cleaned or replaced a needed.

3. This area will be evaluated weekly by the Maintenance Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

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

The facility laundry rooms were observed on 04/09/24 and 04/10/24. The washing machines were of residential type, with no indicator for the water temperature. Staff 5 (Maintenance) reported washing machine rinse temperatures were checked weekly. Review of three months of washing machine temperature checks identified multiple dates where water temperatures were less than 140 degrees F.

The laundry detergent was located in a cabinet in the staff laundry room. The detergent was in two clear bags. There was no label to indicate if a chemical disinfectant was included and there were no instructions for staff on how much to use. Multiple care staff were asked how much detergent was used for a load of soiled linen and the answers were not consistent.

Staff 8 (CG/Laundry) reported she thought there was a disinfectant in the laundry detergent but was unable to confirm.

The need to ensure soiled laundry was properly disinfected was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 04/10/24. They acknowledged the findings.

1. The facility will follow soiled laundry policy per OAR 411-054-0020.

2. The communities laundry detergent contains a  sanitizing agent that does not require the 140 degree rinse temperature. The community will label appropriate storage containers with the product information and dosing requirements for staff information. The facility will post clear instructions in small resident laundry room that soiled linen is not to be rinsed in the sink, rather taken to the staff laundry room and rinsed in the hopper per proper soiled linen protocol.

3. This area will be evaluated weekly by the Health & Wellness Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Technical assistance was provided in the following area:

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:

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

Technical assistance was provided in the following area:

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

Based on observation, 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 372, C 420, C 422, C 513 and C 530.

See plans for C372, C420, C422 C513 & C530.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff completed all required pre-service orientation, 3 of 3 newly hired staff completed all required dementia training topics prior to beginning job duties, 2 of 3 new staff demonstrated competency in all job duties within 30 days of hire, 3 of 3 long-term staff completed the required number of hours of annual in-service training, and that all facility staff completed the Home and Community Based Care training by March 31, 2024. Findings include, but are not limited to:

Staff training records were review on 04/10/24 with Staff 1 (ED) and Staff 4 (Office Manager).

a. There was no documented evidence Staff 4, Staff 7 (CG), Staff 11 (MT) or Staff 14 (MT), hired 04/02/24, 02/06/24, 02/29/24, and 02/24/24, respectively, completed the following pre-service orientation topics prior to beginning their job duties:

* Infectious Disease Prevention; and

* Home and Community Based Care training.

b. There was no documented evidence Staff 7, Staff 11, or Staff 14 completed the required dementia care training topics prior to providing resident care and services independently.

c. There was no documented evidence Staff 7, Staff 11, or Staff 14 demonstrated competency in one or more assigned duties within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADLs;

* Identification, documentation, and reporting changes of condition;

* Conditions which require assessment, treatment, observation, and reporting;

* General food safety, serving, and sanitation; and

* Other duties as applicable (e.g., med pass, treatments).

d. There was no documented evidence Staff 6 (CG), hired 04/02/19, Staff 13 (MT), hired 03/05/19 or Staff 12 (MT), hired 09/15/18 completed 16 hours of annual in-service training, with 10 hours being related to the provision of care in Community Based Care and six hours related to dementia care.

e. Staff 1 stated that other than herself, no staff had completed the Home and Community Based Care training that was required to have been completed by all staff by March 31, 2024.

The need to ensure all staff training was completed in the required time frames was discussed with Staff 1 and Staff 4 on 04/10/24. They acknowledged the findings.

See plan for C372.

Based on interview and record review, it was determined the facility failed to ensure that 1 of 1 sampled resident, (#2), had a diagnosis of dementia and was in need of support for the progressive symptoms of dementia for safety, physical or cognitive function prior to being admitted to the memory care community. Findings include, but are not limited to:

Resident 2 moved into the facility in 02/2024 with diagnosis including multiple myeloma.

The resident's clinical record including current physician orders, MAR's dated 03/01/24 -04/07/24, and move-in evaluation dated 01/30/24 were reviewed and identified the following:

There was no documented evidence the resident had a diagnosis of dementia or other diagnosis required to reside in a memory care community.

The need to ensure that residents residing in the memory care community had a clear diagnosis of dementia which was progressive and required a secured environment for safety, physical or cognitive function was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 3 (Regional RN) on 04/10/24. They acknowledged the findings and provided survey with a written plan to address the resident's level of care and diagnosis.

1. Resident 2 has received the appropriate diagnosis for memory care placement per OAR 411-054-0160.

2. All parties involved in performing pre-move in evaluations will be inserviced in the proper usage of the tool. They will also be inserviced on the proper admitting diagnoses per OAR 411-057-0160. This inservice will be completed by 6/9/2024.

3. This area will be evaluated weekly by the Health & Wellness Director.

4. The Executive Director will monitor that this system is being followed daily at stand up.

Based on 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 252, C 282 and C 320.

See plans for C252, C282 & C320.