Print Inspection: O2U3

The findings of the re-licensure survey, conducted 07/08/24 through 07/11/24, 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 and OARs 411 Division 004 for 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 07/11/24, conducted 10/22/24, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents for 1 of 1 sampled resident (#6) who fell outside on the facility property. The resident sustained injuries and ongoing pain as a result of the fall. Findings include, but are not limited to:

Resident 6 moved into the facility in 04/2024 with diagnoses including vascular dementia. The resident's 04/27/24 through 07/08/24 progress notes and incident reports were reviewed, interviews with staff and the resident were conducted, and observations of the facility property were made. The following was identified:

* A progress note dated 06/03/24 indicated the resident experienced a fall "in pond outside";

* An incident report dated 06/03/24 stated, "Resident...had fallen in the pond in our courtyard...Resident was cold...wet from [his/her] waist down and up [his/her] [right] side to [his/her] head, which was also wet...Resident...was standing and or wandering in the smoking gazebo. Resident stated [she/he] accidentally stepped off the edge of the patio, falling backwards and tumbling down the hill into the pond." The incident report also noted the resident was assessed and had a skin tear and bruising on his/her right forearm; and

* Subsequent progress notes from 06/04/24 to 06/06/24 stated, "Resident was [complaining of] 8/10 pain all around...8/10 right elbow pain...[complaining of pain, especially on [his/her] right-side elbow and ribs."

Observations of the facility courtyard were made on 07/09/24. In the area of the smoking gazebo there were dropoffs near the edge of the pond of two to five inches. Observations of the pond revealed a bare dirt slope, rocky in some places, at a depth of approximately six feet. There was a blue rope about 0.5 inch in diameter hanging loosely around the pond. Survey requested a plan to enclose the pond to provide a barrier around the perimeter. The pond was enclosed with temporary fencing on 07/10/24.

During an interview at 9:15 am on 07/10/24, Staff 10 (MT) confirmed there was no barrier in place between the pond and the patio at the time of the resident's fall.

The resident sustained a skin tear, bruising, and ongoing widespread pain as a result of falling into the facility pond.

The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 07/11/24. They acknowledged the findings.

1.  Installed a temporary fence around run off area.  Met with vendors to get an install date for fence.  Fence to be installed mid-August.  Temporary fencing will remain in place until new fence is installed.  Made a complete walk through of the grounds to ensure there were no other hazards which could effect the health, safety or welfare of residents.

2.  Fence will be installed to prevent any further possibility of a resident falling into the run off.  Plant Ops will conduct monthly inspections of the exterior and interior of the community to identify if any conditions threaten the health, safety and welfare of residents.  If conditions are found during these inspections they will be corrected as needed.

3.  Monthly inspections reviewed as part of the Continuous Quality Improvement (CQI) process.

4.  Maintenance Director and Executive Director.

Based on observation, interview, and record review, it was determined the facility failed to immediately notify the local SPD office of any incident of abuse/neglect or suspected abuse/neglect for 1 of 1 sampled resident (# 6) who had reportable incidents. Findings include, but are not limited to:

Resident 6 moved into the facility in 04/2024 with diagnoses including vascular dementia. The resident's 04/27/24 through 07/08/24 progress notes and incident reports were reviewed, interviews with staff and the resident were conducted, and observations of the facility property were made. The following was identified:

* A progress note dated 06/03/24 indicated the resident experienced a fall "in pond outside";

* An incident report dated 06/03/24 stated, "Resident...had fallen in the pond in our courtyard...Resident was cold...wet from [his/her] waist down and up [his/her] [right] side to [his/her] head, which was also wet...Resident...was standing and or wandering in the smoking gazebo. Resident stated [she/he] accidentally stepped off the edge of the patio, falling backwards and tumbling down the hill into the pond." The incident report also noted the resident was assessed and had a skin tear and bruising on [his/her] right forearm; and

* Subsequent progress notes from 06/04/24 to 06/06/24 stated, "Resident was [complaining of] 8/10 pain all around...8/10 right elbow pain...[complaining of pain, especially on [his/her] right-side elbow and ribs."

Observations of the facility courtyard were made on 07/09/24. In the area of the smoking gazebo there were dropoffs near the edge of the pond of two to five inches. Observations of the pond revealed a bare dirt slope, rocky in some places, at a depth of approximately six feet. There was a blue rope about 0.5 inch in diameter hanging loosely around the pond. Survey requested a plan to enclose the pond to provide a barrier around the perimeter. The pond was enclosed with temporary fencing on 07/10/24.

During an interview at 9:15 am on 07/10/24, Staff 10 (MT) confirmed there was no barrier in place between the pond and the patio at the time of the resident's fall.

The fall into the pond constituted possible neglect which required immediate reporting to the local SPD office. In an interview at 1:32 pm on 07/09/24, Staff 2 (Regional Director of Operations) stated the incident had not been reported. Survey requested the incident be reported and confirmation was received at 12:00 pm on 07/10/24.

The need to ensure the facility immediately reported all incidents of abuse/neglect or suspected abuse/neglect was discussed with Staff 1 (ED) and Staff 2 on 07/11/24. They acknowledged the findings.

1.  Interim ED (RDO) reported incident to APS.

2.  ED/RDO and Clinical team reviewed abuse and neglect reporting guidelines.  Facility will report any incident to APS where abuse and neglect cannot be ruled out.  Staff have been reeducated to report potential abuse and neglect to their direct supervisor immediately.

3. ED and Clinical team will review all incidents during daily stand up/clincal meeting and as necessary to determine if self reporting is required.

4.  Executive Director

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 long-term staff (#s 8 and 9) completed a minimum of 12 hours of inservice training annually, including six hours of dementia care training. Findings include, but are not limited to:

Staff training records were reviewed with Staff 4 (Administrative Assistant) at 11:30 am on 07/09/24. The following was identified:

There was no documented evidence Staff 8 (MT), hired 07/09/18, and Staff 9 (MT), hired 06/05/19, completed six hours of annual dementia care training during the review period of 07/09/23 to 07/09/24 and 06/05/23 to 06/09/24, respectively.

The need to ensure long-term direct care staff completed all annual training requirements was discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 07/11/24. They acknowledged the findings.

1.  The facility conducted a full audit of all employee training to determine anyone who is out of complaince with their annual training and ensured completion.

2.  Business Office Manager will maintain current training grid and ensure completion of all annual training timely.

3.  Monthly review during the CQI process to ensure all training is completed and up-to-date.

4. Executive Director

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire and life safety records, dated between 01/2024 and 06/2024, were reviewed and revealed the following:

a. The facility failed to relocate or evacuate residents during fire drills; therefore, documentation was lacking in the following areas:

* The escape route used;

* Problems encountered, comments relating to residents who resisted or failed to participate in the drills;

* Evacuation time-period needed;

* The number of occupants evacuated; and

* Evidence alternate routes were used during fire drills.

The need to ensure fire drills were conducted according to the OFC was reviewed with Staff 1 (Executive Director), Staff 2 (Regional Director of Operations), Staff 5 (LPN), and Staff 7 (RCC) on 07/11/24. They acknowledged the findings.

1.  Fire Drill for Assisted living completed.  Residents were relocated from one zone to another.  All following areas documented in the drill - escape route used, problems that came up during the drill, time it took for the evacuation, number of occupants evacuated, what alternate routes were used during the drill and record of anyone who was not able to participate with documented training/review of the process.  Regulations for the fire drill process have been reviewed with Maintenance Director to ensure understanding of the requirements.

2.  Fire drills will be held every other month with correct documentation.

3.  Fire drill conducted every other month per regulation.  Fire Drills and Fire and Life Safety reviewed monthly during the CQI process.

4.  Maintenance Director and Executive Director.

Based on observation and interview, it was determined the facility failed to ensure all chemicals and other toxic materials were in a locked storage unit, and exterior pathways were maintained in good repair. Findings include, but are not limited to:

During a tour of the facility on 07/08/24 at 1:30 pm the following was identified:

* Cleaning materials were observed on the third floor in the cabinet under the sink in the kitchenette area of the craft room used by residents and in the cabinet under the sink in the residential laundry room. Both cabinets were not locked or secured. The doors to the craft room and residential laundry room were found to be unlocked, allowing residents full access to the cleaning materials at all times; and

* The concrete walkway leading to the "dry pond" the smoking area and patio adjacent to the dry pond contained numerous drop-offs of up to approximately five inches from the surface of the concrete to the adjacent soil, creating a potential fall hazard for residents who used the walkway, smoking area and patio.

The drop-offs and unlocked cleaning materials were shown to and discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 07/09/24 at 1:57 pm. They acknowledged the findings.

1.  Facility conducted a thorough sweep to ensure all cleaning chemicals are locked and staff were all trained of keeping these locked.  Locks were assessed and repaired as necessary.  During All staff meeting all staff were reminded to keep chemicals locked.

All outside drop offs on walkways were filled with bark dust.

2. Monthly walk through for maintenance of cleaning chemical storage compliance and monthly walk through of general exterior compliance and make corrections as needed. New hires are trained on keeping chemicals stored properly during their intitial orienation.

3. Facility will review the monthly audit to ensure general exterior compliance during the CQI process.  

4. Executive Director and Maintenance Director  

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

The facility was toured on 07/08/24 at 1:30 pm.

a. The following areas needed repair:

* Light fixtures throughout each of the facility's three stairwells had cracked, broken, or missing covers;

* The windowsill in second floor residential laundry room was warped and damaged;

* A non-functioning dryer (with a missing internal drum) in the third floor residential laundry room needed repair or removal; and

* Exterior wood surrounding doors leading to first floor resident patios facing the courtyard area had rotting wood and flaking and peeling paint.

b. The following areas needed cleaning:

* Areas behind washer and dryer in the second and third floor residential laundry room had loose exhaust ducts and were covered with dust and lint; and

* The carpets in resident rooms 110, 212, and 218 were soiled and stained.

The building was toured and areas needing cleaning or repair were discussed with Staff 1 (ED) and Staff 2 (Regional Director of Operations) on 07/09/24 at 1:57 pm. They acknowledged the findings.

1.  Light fixture covers in disrepair were all replaced.  Second floor window sill was repaired.  Malfunctioning dryer was removed.

Facility is working with vendors to schedule the repair for the patio doors on first floor with rotting wood.

All laundry rooms were thoroughly cleaned including behind ther washer and dryer.  Ducts in laundry room were repaired.

Carpet in resident room 110, 212 and 218 was reviewed and discussed with resident and cleaned as allowed.

2.  Facility will conduct audits to identify concerns with general building maintenance and cleanliness.  Laundry rooms will be throroughly cleaned monthly.  Annual carpet deep cleaning will be scheduled for resident apartments.  Facility to conduct monthly audit to ensure cleanliness and good repair.  Laundry rooms will be thoroughly cleaned monthly.  Carpets in resident apartments deep cleaned annually per schedule and as needed.

3.  Reviewing audits monthly during the CQI audit to ensure compliance.

4.  Executive Director

Based on observation and interview, it was determined the facility failed to ensure covers, grates, or screens of wall heaters did not exceed 120 degrees Fahrenheit when installed in locations which were subject to incidental contact by individuals or with combustible material. Findings include, but are not limited to:

Observations of the facility made on 07/08/24 revealed wall heaters present in multiple sampled and unsampled resident units, as well as in the first-floor ice cream parlor. The heater in the ice-cream parlor on the first floor was located in an area subject to incidental contact by residents, and testing by the surveyor showed the wall heater cover reached 131.2 degrees Fahrenheit. During a tour of the building on 07/09/24 at 1:57, Staff 1 (ED) was not aware if there was a system to ensure the temperatures of the wall heaters remained below 120 degrees Fahrenheit.

The need to ensure heating surfaces did not exceed 120 degrees Fahrenheit when located in areas where incidental contact could occur was discussed with Staff 1 and Staff 2 (Regional Director of Operations) on 07/09/24 at 1:57 pm. They acknowledged the findings.

1.  Heater in ice cream parlor has been disconnected to prevent from reaching a temperature exceeding 120 degrees.   All resident heaters have been checked to ensure all heaters do not reach over 120.

2.  All heaters were checked and will be maintained to ensure they do not reach or exceed 120 degrees.  Maintenance will check during monthly facility audit to identify concerns.  Every apartment heater will be checked semi-annually as part of our environmental evaluation and any time there is an apartment being turned to ensure safety.

3.  Reviewed monthly audit as part of the CQI process.

4.  Executive Director and Maintenance Director