Print Inspection: J8ZV

The findings of the re-licensure survey, conducted 06/06/22 through 06/08/22, 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 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

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 licensure survey of 06/08/22, conducted on 07/13/22, 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 57 for Memory Care Communities.

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

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 06/08/22, conducted on 09/26/22, 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 57 for Memory Care Communities.

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

Review of facility records on 06/07/22 identified the following deficiencies:

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

On 06/07/22 the need to provide fire and life safety instruction to staff, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations) and Staff 5 (Maintenance Assistance).  They acknowledged the findings.

Facility will meet regulation with documentation from Plant Ops Department on alternate monthly meetings with staff and residents to discuss fire and life safety instruction on different shifts. Documentation will include, but not limited to: date, time, type of training (fire drill or verbal instruction), names of residents and staff present, location, and problems encountered. Continued instruction, teaching, and guidance will be provided by Director of Plant Ops or Designee.

Based on interview and record review, it was determined the facility failed to provide fire and life 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 06/07/22 identified the following deficiencies:

There was no documented evidence that annual training on fire safety was provided to residents. This included residents in the memory care units, whose cognitive abilities allowed engagement in such instruction, and residents in the facility's RCF.

On 06/07/22 the need to provide and document fire and life safety instruction for residents, at least annually, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations) and Staff 5 (Maintenance Assistant). They acknowledged the findings.

Facility will meet regulation with documentation from Plant Ops Department and/or administrator providing instruction on fire and life safety to all residents within 24 hours of move-in and annually on topics such as: safety procedures, evacuation methods, evacuation locations, and responsibilities during fire drills.

Based on observation and interview, 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 510.

Facility will maintain compliance with regulation by padding all droppoff in courtyards with barkdust

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were properly labeled and maintained in a locked storage unit, and failed to ensure exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents. Findings include, but are not limited to:

On 06/06/22, an interior and exterior tour of the facility identified the following deficiencies:

* Outdoor courtyard/patio areas contained drop off's, up to an inch and a half in depth, creating a possible trip hazard for residents;

* Cleaning chemicals were observed accessible to the residents in unlocked cabinets in the kitchenette of cottage "B"; and

* Multiple buckets were observed in resident courtyards that contained deicer and were not properly labeled.

On 06/06/22, ensuring all toxic materials were properly labeled and maintained in locked storage to avoid access by residents, and the need to ensure all exterior pathways were maintained in good repair, was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant). They acknowledged the findings.

Facility met regulation on 6/6/2022 by instructing housekeeping to move all chemicals to a locked laundry room and removed de-icer buckets away from accessible areas, such as outside entryway; updated daily checklist will be provided to plant ops department. Facility will meet regulation and be in compliance with drop offs by either contracting with landscapers and/or facility in adding more dirt in drop off and decreasing the likelihood of a trip hazard on or by 6/30/2022. Monthly continued follow up will be by Plant Ops Department and Administrator to ensure that drop offs stay level with sidewalk, weekly and environmental round checklist will be updated to ensure weekly walkthrough of drop-offs to maintain compliance.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and toxic materials were maintained in a locked storage unit, and failed to ensure exterior pathways were maintained in good repair and did not contain drop offs to prevent tripping hazards for residents. This is a repeat citation. Findings include, but are not limited to:

On 07/13/22, an interior and exterior tour of the facility with Staff 1 (Administrator) and Staff 5 (Maintenance Assistant) identified the following deficiencies:

* Outdoor courtyard/patio areas contained drop off's, up to three inches in depth, creating possible tripping hazards for residents in cottages A, B, D and E; and

* Cleaning chemicals were observed accessible to the residents in unlocked cabinets in the kitchenette of cottages A and B.

On 07/13/22, the need to ensure all toxic materials were maintained in locked storage to avoid access by residents, and the need to ensure all exterior pathways were maintained in good repair, was discussed with Staff 1 and Staff 5. They acknowledged the findings.

Facility will meet regulation by instructing housekeeping and caregivers to move all chemicals to a locked laundry room and keep cabinets locked at all times. Locks for dishwasher chemicals, under sink, have been ordered and will be installed

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 (F) when installed in locations that were subject to incidental contact by individuals. Findings include, but are not limited to:

On 06/06/22, a fireplace was observed in the common area of cottage "E". The fireplace was located where residents could come into incidental contact with it. The glass surface of the fireplace, measured with the surveyor's thermometer, was above 150 degrees F. Surveyor informed Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant) that the fireplace could not exceed 120 degrees F. Staff 5 reported they would turn off the fireplace and Staff 1 reported they would put a memo out to staff to not utilize the fireplace until a cover could be obtained.

On 06/07/22, the fireplace in cottage "E" was observed to be on and the glass surface temperature, measured with the surveyor's thermometer, was again above 150 degrees F. Surveyor informed Staff 5 to turn turn off the gas to the fireplace until a fireplace cover could be obtained. The fireplace and gas was later observed as turned off on 06/08/22.

On 06/06/22, the need to ensure the surfaces around the fireplace did not exceed 120 degrees F was discussed with Staff 1 (Administrator), Staff 4 (Director of Plant Operations), and Staff 5 (Maintenance Assistant). They acknowledged the findings.

Facility will meet regulation by installing fireplace grate/screen in E House. Follow ups will be conducted by Plant Ops Department and/or Administrator weekly and updated environmental rounds checklist will be created to ensure compliance.

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 420, C 422, C 510 and C 540.

Facility will follow licensing rules and regulations by ensuring POC is collaborated with Plant Ops Department, ensure implementation of POC, and continued monitoring of effectiveness of interventions; checklists will be updated and will be discussed at weekly meetings and environmental rounds will be conducted weekly.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:

Refer to C 510.

Facility will follow licensing rules and regulations by ensuring POC is followed in a collaborative effort with all departments within the facility to ensure implementation of POC and continued monitoring of effectiveness of interventions; checklists, training records, and rosters will be updated, to reflect discussions at trainings & fire drills; environmental rounds will be conducted weekly to ensure drop-offs are within compliance.

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 sampled direct care staff (#s 6, 7, 8 and 13) completed the required number of hours of annual training. Findings include, but are not limited to:

Training records were reviewed with Staff 19 (Business Office Manager) on 06/07/22 and identified the following:

* Staff 6 (CG), hired on 04/15/19, Staff 7 (MT), hired on 08/26/19, Staff 8 (CG), hired on 11/22/04, and Staff 13 (CG), hired on 05/30/06, lacked documentation of completing the required ten hours of annual training related to provision of care in community-based care or the required six hours related to dementia care.

The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (Administrator) and Staff 19 on 06/08/22. They acknowledged the findings.

Facility will ensure compliance with staff trainings by added 30 minutes at monthly staff trainings (1.5 hours total), updating CEU records, and implementing outside agencies and articles on dementia related topics and education to meet 16 hours of continuing education trainings annually.