Print Inspection: H64H

The findings of the re-licensure survey, conducted 01/08/24 through 01/10/24, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities 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 re-visit to the re-licensure survey of 01/10/24, conducted 04/08/24 through 04/09/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

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 second revisit to the re-licensure survey of 01/10/24, conducted on 06/25/24, 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, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. Findings include, but are not limited to:

During the survey, 01/08/24 through 01/10/24, observations of the unit showed a puzzle and coloring were offered twice and one group activity, which consisted of yoga class, was conducted inside the memory care unit.

In an interview on 01/09/24, Staff 1 (Interim Administrator) indicated the current activity coordinator was new to the roll and filling in at this time. The facility was working to permanently fill the position.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1, Staff 2 (RN), Staff 3 (RCC) and Staff 10 (Activity Director) on 01/09/24. The staff acknowledged the findings.

New Life Enrichment Coordinator (LEC) will be hired and trained

All staff will be retrained to review daily activity calendar and assist if needed, or if LEC is not present.  LEC will track activities and attendance

Monthly

LEC and Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily program of social and recreational activities that were based upon individual and group interests and physical, mental, and psychosocial needs was provided for residents. This is a repeat citation. Findings include, but are not limited to:

During the survey, 04/08/24 through 04/09/24, observations of the unit showed coloring was offered once and one group activity, which consisted of a visiting musician, was conducted inside the memory care unit.

The facility Daily Activity Rolls for April were reviewed. The Daily Activity Rolls were blank for April 2nd, 4th, 5th, 6th, and 7th.  A sing-a-long activity was documented as completed on 04/03/24.

The April Activity calendar had Yoga, balloon toss, and crosswords scheduled for 04/08/24. None of the activities were conducted.

In an interview on 04/08/24, Staff 1 (Interim Administrator) indicated the Staff 10 (Life Engagement Coordinator) was new to the position and developing the program. She explained Staff 10 also assisted with covering the floor during staff shortages.

The need to ensure a daily activity program was provided for residents was reviewed with Staff 1 and Staff 10 (Life Engagement Coordinator) on 04/09/24. The staff acknowledged the findings.

Activities Calendar will reflect activities offerred .  Activities will be incorportated into the daily routine.

New staff will receive training from LEC on how to document activties daily.  LEC will review activity logs and retrain as needed

Weekly

LEC and Administrator

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:

There was no evidence the facility had fully implemented an ABST that would determine a staffing plan to meet the 24-hour scheduled and unscheduled needs of residents.  All facility residents were not entered into the tool.

The requirements of the ABST were discussed with Staff 1 (Interim Administrator) on 01/08/23. She acknowledged the facility failed to ensure a staffing tool was in place, fully implemented with all residents accurately entered, to determine needed staffing.

Training on ABST tool will be completed and data entered.  Use of tool will be implemented

Once implemented, tool will be used

Monthly

Administrator

Based on interview and record review, it was determined the facility failed to conduct fire drills at different times of the day, evening, and night shifts. Findings include, but are not limited to:

Fire drill records for 06/10/23 - 12/21/23 were reviewed.

All drills were conducted between 4:52 am and 8:21 am. No drills were conducted on the evening shift.

In an interview with Staff 6 (Maintenance) on 01/09/24, he acknowledged  there were no fire drills conducted on the evening shift.

The need to ensure the facility was in compliance with all required fire drill requirements was discussed with Staff 1 (Interim Administrator) on 01/10/24. She acknowledged the need for fire drills on all shifts.

Fire Drill will be conducted on evening shift.  Current Policies and Procedures for Fire & Life Safety drills will be reviewed

Per policy, drills to be conducted monthly on rotating shifts so all shifts receive training

Monthly

Maintenance and Administrator

Based on interview and record review, it was determined the facility failed to provide fire safety instruction to residents at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Review of facility records on 01/09/24 and an interview with Staff 6 (Maintenance) identified there was no documented evidence training on fire safety was provided to residents at least annually.

On 01/10/24, the need to provide and document fire safety instruction to residents at least annually, in accordance with the OFC, was discussed with Staff 1 (Interim Administrator). She acknowledged the findings.

Conduct annual training with residents.  Per current policy, annual training to be conducted with residents

Annual training will be documented in CC and added to audit schedule

Annually

Maintenance and Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include but are not limited to:

Refer to C 242 and Z 155.

Implement a weekly system check of data

implimenting a weekly check of data

Weekly

LEC and Administrator

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

During a tour of the environment on 01/08/24 and 01/09/24, the following areas were observed to be in need of repair:

* Baseboard molding damaged in multiple areas, exposing particle board;

* Handrails chipped on the corners in several locations creating splintered areas;

* Damage to walls in halls on corners exposing drywall;

* Missing drawer panel under the sink in room 128;

* Missing cover to heater in room 145, exposing internal components; and

* Broken window in room 135, outer of pane of double paned window.

The areas in need of repair were reviewed with Staff 6 (Maintenance) on 01/09/24. He acknowledged the areas. The heater in room 145 was immediately repaired.

On 01/09/24, the areas in need of repair were reviewed with Staff 1 (Interim Administrator). She acknowledged the findings.

Items noted to be repaired

Routine environmental audits of MC neighborhood to be conducted.  Any needed repairs will be completed

Monthly

Maintenance and Administrator

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 242, C 361, C 420, C 422 and C 513.

Individual citations and areas noted will be corrected, per POC

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 242.

Individual citations and areas noted  will be corrected per POC

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 5, 8, and 11) had documentation of demonstrating competency in all required areas within 30 days of hire. The facility failed to ensure 3 of 3 sampled staff (#s 7, 8, and 9) completed 16 hours of annual in-service training, including infectious disease outbreak and infection control. Findings include, but are not limited to:

Staff training records were reviewed on 01/09/24 and 01/10/24.

a. Staff 5, hired 10/09/23, Staff 8, hired 11/10/23, and Staff 11, hired 10/9/23, all MT's, lacked documented evidence of demonstrating competence in all job duties, including medication pass, within 30 days. All staff demonstrated competence in medication pass on 01/09/24.

b. Staff 14 (MT), hired 11/20/22, Staff 15 (CG) hired 08/27/20, and Staff 17 (MT), hired 10/06/20, lacked evidence of 16 hours of annual in-service training based on anniversary of hire dates.

c. Staff 7 (Cook), hired 09/15/20, Staff 15 (CG), hired 08/27/20, and Staff 17 (MT), hired 10/06/20, lacked evidence of completing annual training on infectious disease outbreak and infection control.

The need to ensure staff demonstrated competence in all job duties within 30 days, and completed annual training including infectious disease outbreak and infection control, was discussed with Staff 1 (Interim Administrator) on 01/10/24. She acknowledged the findings.

All training and certifications, per CPM policy and DHS regulation, will be brought up to date.  Requirements will be reviewed with staff

Training, certification and skills competency lists will be entered into CC system and audited

Monthly

Office Manager and Administrator

Based on interview and record review, it was determined the facility failed to ensure 1 of 2 sampled newly-hired staff (#19) had completed pre-service dementia training and documentation of demonstrating competency in all required areas within 30 days of hire. This is a repeat citation. Findings include, but are not limited to:

Staff training records were reviewed on 04/08/24 and 04/09/24.

Staff 19 (MA), hired 03/07/24, lacked documented evidence of completing pre-service dementia training and demonstrating competence in all job duties, including medication pass, within 30 days.

Staff 1 (Interim Administrator) explained Staff 19 was working independently and passing medications.  Staff 19 demonstrated competence in medication pass on 04/09/24 prior to beginning her shift.

The need to ensure staff completed all required pre-service training and demonstrated competence in all job duties within 30 days was discussed with Staff 1 (Interim Administrator) on 04/09/24. She acknowledged the findings.

All training and certifications, per CPM policy and DHS regulation, will be brought up to date.  Requirements will be reviewed with staff.

Trainings, certifications, and skill competancy lists will be entered into CC system and audited by CRM/OM

At least monthly and also weekly for new hires until they are cleared to work independently.

Communty Relations Administrator and Administrator

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations and individualized activity plans were completed for 2 of 2 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 and 2's service plans offered some information about residents' interests, but the facility had not fully evaluated the residents' activity needs in one or more of the following areas:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities which could be used as behavioral interventions, if necessary.

There were no resident-specific activity plans developed from activity evaluations which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities.

Observations between 01/08/24 and 01/10/24 showed one group activity being led by facility staff and minimal individual activities.  

The need to ensure activity evaluations were completed for all residents, and individualized activity plans developed and implemented was discussed with Staff 1 (Interim Administrator), Staff 2 (RN), Staff 3 (RCC) on 01/09/24. The staff acknowledged the findings.

Individualized activity plans will be completed for each resident.  New LEC will be hired and trained

Individualized plans will be completed upon move in and reviewed with service plan updates

Quarterly

LEC and Administrator