Print Inspection: QHUJ

The findings of the re-licensure survey, conducted 10/24/22 through 10/26/22, 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, 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 revisit to the re-licensure survey of 10/27/22, conducted 03/22/23 through 03/23/23 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, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities.  

2. Observations of the MCC pantry from 10/24/22 through 10/26/22 showed the following:

* Debris, spills and stains were noted inside numerous drawers, cupboards and down walls. Cupboard shelves had scrapped and peeling surfaces;

* Transitions between flooring and doorways had dark accumulation and debris;

* Spills and debris were noted on the refrigerator shelves and surfaces;

* Debris and dark accumulation was noted along the edges of the floor underneath the cupboards and at the sides of the refrigerator;

* A gray/blue clump of mold was noted in the cupboard under the sink, as well as black debris, brown stains and multiple peeling surfaces;

* Counter tops had cracked and/or missing edges which exposed the untreated surface underneath;

* Debris was noted on the inside of the microwave;

* A crockpot was noted with approximately an inch of standing water with debris inside;

* Meals delivered to the MCC unit had uncovered desserts on an open shelf of the cart for multiple meals;

* Staff plating foods from inside the kitchenette and delivering plates to residents, did not have aprons in place over clothing; and

* Staff inconsistently utilized proper hand hygiene between clean and dirty tasks, glove changes and meal delivery/plating.

The need to ensure the pantry was clean and in good repair and that staff utilized appropriate hand hygiene during meal serving/delivery was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN) on 10/24/22 and 10/25/22. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

A survey of the first-floor kitchen was completed previously by Nursing Facility surveyors on 07/01/22.

The second-floor kitchen was toured on 10/24/22 and showed the following:

* Brown build-up on the floor at the baseboard juncture throughout kitchen;

* Dust build-up on kitchen fans, including fan above clean dishes exiting the ware washer;

* Black debris on full length of windowsill;

* Gouges on walls in multiple areas exposing drywall, creating an uncleanable surface;

* Paper signs throughout kitchen, creating an uncleanable surface; and

* Garbage cans throughout the kitchen did not have lids.

These findings were reviewed with Staff 19 (Kitchen Manager) and Staff 20 (Dining and Food Services Director) on 10/25/22 and with Staff 3 (ALF Administrator) on 10/26/22. They acknowledged the findings.

All areas in the kitchen and pantry observed to be unclean during survey process have been cleaned.  Garbage cans with lids have been ordered and papers have been taken down and replaced with papers in plastic wipeable sleeves.  

Aprons have been purchased and staff have been retrained on proper hand hygeine.  

Desserts are now covered for delivery.

Daily cleaning assignments/tasks have been delegated to staff.  Weekly deep clean days with additional heavy duty cleaning tasks have been implemented.  

Cabinet Demo and removal of hallway door starts on the December 12th

New flooring on the December 13th 2022

Paint ceiling on the December 14th 2022

FRP installed on the December 15th and 16th 2022

new cabinetry and countertops December 19th and 20th 2022

reinstall plumbing on the December 21st 2022

Finished on the December 22nd 2022

The MC Administrator and or designee will walk panty daily to assure ongoing compliance with cleanin will remain intact.  Dining Services Director will audit kitchen weekly.   

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (# 1) whose move in evaluation was reviewed. Findings include, but are not limited to:

Resident 1 was admitted to the facility in September 2022 with diagnoses including dementia.

Observations of the resident, interviews with staff and review of the resident's record were completed between 10/24/22 and 10/26/22.

The new move-in evaluation and Level of Care form dated 09/28/22 did not address the following required elements:

* Visits to health practitioner(s), ER, hospital, or nursing facility in the past year;

* Vital signs if indicated by diagnosis, health problems or medications;

* Mental health issues including history of treatment and non-drug interventions;

* Cognition including memory, orientation and confusion;

* Personality, including how the person copes with change or challenging situations;

* Ability to understand;

* Dental status and assistive devices;

* Nutrition habits, fluid preferences and weight if indicated;

* History of dehydration or unexplained weight loss;

* Recent losses;

* Smoking;

* Unsuccessful prior placements;

* Customary routines: eating, bathing; and

* Environmental factors that impact the resident's behavior, including noise, lighting, and room temperature.

The need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN) on 10/26/22. They acknowledged the findings.

Resident 1's evaluation has been updated to include all missing fields identified in survey.

Person's responsible for Evaluations have been retrained on required componants of the evaluations.

A sample of evaluations will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs.

A monthly evaluation report to be generated to determine due dates and ensure compliance.

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

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 1 of 2 sampled residents (# 3) who experienced changes of condition. Findings include, but are not limited to:

Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia.

Interviews with staff and review of the resident's 08/29/22 service plan, 07/01/22 through 10/22/22 progress notes, incident investigations and physician communications were completed.

a. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:

* Hospice admission;

* New medications and medication changes;

* Skin issues including bruising, skin tears and rashes; and

* Weakness, ER visits and falls.

b. The resident experienced non-injury falls on 08/14/22, 08/18/22 and 10/05/22.

There was no documentation in the resident's record the facility had completed thorough investigations of the falls to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness.

The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN) on 10/26/22. They acknowledged the findings.

Resident identified in survey as having insufficient monitoring has had record review to ensure all change of conditions are addressed and that service plan reflects current needs.  

Staff responsible for change of condition monitoring will be retrained on required elements of change of condition monitoring.  

Clicinal meeting to be held at least weekly to ensure change of conditions are being addressed and monitored and that staff is made aware of short and long term care need changes.

Monthly audit of sample of residents with change of condition will be reviews to ensure monitoring is in place and staff are made aware.  

MC Administrator, AL Administrator and Director of Health Services are responsibe to see that the corrections are completed and monitored.  

Based on interview and record review, it was determined 3 of 4 sampled, newly hired direct care staff (#s 7, 10 and 13) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

A review of the facility's training records on 10/24/22 and again on 10/25/22 revealed:

Staff 7 (CG/MT), Staff 10 (CG) and Staff 13 (CG/MT), hired 03/31/22, 09/06/22, and 09/19/22, respectively, did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.

The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (MCC Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required trainings and documentation verifying training is in place.

Auditing tools are now in place and Staffing Coordinator has been retrained on required training and documentation needed for new employees.  

The Staffing Coordinator will give weekly reports to the Administrator.  Training documentation will be reviewed weekly.  

The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored.   

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training was documented as completed on alternating months for memory care staff. Findings include, but are not limited to:

Fire drill records were reviewed from April 2022 to August 2022.

The following deficiencies were identified:

* There was no documented evidence that fire life safety training was conducted on alternating months from the fire drills; and

* Fire drill records lacked documentation on all required components, including escape route used, evacuation time period needed, number of occupants evacuated and evidence of alternate routes used.

In interview on 10/24/22, Staff 4 (Maintenance) indicated he regularly discussed fire drill procedures with the memory care staff and simulated possible scenarios. They did not move actual residents around the unit during a drill.

The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (MCC Administrator) and Staff 4 on 10/24/22 and 10/26/22. The staff acknowledged the findings.

Person's responsible for Fire Life safety training and drills has been retrained on fire life safety training and documenatation.  Missing componants in documentation have been added to training materials.

The Facility Ops director has updated the training schedule and training requirements.

Fire Life Safety training records will be reviewed monthly.  

The Facility Operations Director and Adiminstrator will be responsible to see that the corrections are completed and monitored.  

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 C240, C372 and C420.

Refer to C240, C372 and C420

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 training areas prior to beginning work on the floor and demonstrated competency in all required areas within 30 days of hire and 4 of 4 long-term staff completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 10/24/22 and 10/25/22. The following was identified:

a. There was no documented evidence Staff 7 (CG/MT), Staff 10 (CG), Staff 11 (CG), Staff 13 (CG/MT), hired 03/31/22, 09/06/22, 04/07/22 and 09/19/22, respectively, completed all required pre-service training prior to starting work, including:

* Resident rights and values of CBC care;

* Abuse Reporting requirements;

* Infectious Disease Prevention;

* Written job description;

* Dementia disease process including progression of the disease, memory loss and psychiatric & behavioral symptoms;

* Techniques for understanding, communicating and responding to distressful behavioral symptoms;

* Strategies for addressing social needs and engaging persons with dementia in meaningful activities;

* Specific aspects of dementia care and ensuring safety of residents with dementia;

* Environmental factors that are important to a resident's well-being;

* How to provide personal care to a resident with dementia including an orientation to the resident's service plan; and

* Use of supportive devices with restraining qualities in memory care communities.

b. There was no documented evidence Staff 7 (CG/MT), Staff 10 (CG), Staff 11 (CG), Staff 13 (CG/MT), hired 03/31/22, 09/06/22, 04/07/22 and 09/19/22, respectively, demonstrated competency in the following areas within 30 days of hire:

* Role of service plans in providing individualized care;

* Providing assistance with ADL's;

* Changes associated with normal aging;

* Identification, documentation, and reporting of changes of condition;

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

* General food safety, serving and sanitation.

c. There was no documented evidence Staff 8 (CG/MT) hired 09/16/20, Staff 12 (CG) hired 01/08/21 and Staff 14 (CG) hired 05/31/17, completed the required number of hours of annual in-service training, including dementia training in 2021 through 2022. Training records reviewed were 09/2021-09/2022, 01/2021-01/2022 and 05/2021-05/2022, respectively.

Staff 1 (MCC Administrator), Staff 3 (ALF Administrator), Staff 16 (Human Resources Manager) and Staff 17 (Human Resources) located as many documents as they could between 10/24/22 and 10/26/22. Staff 1 and Staff 3 understood the staff training system was incomplete and they were in the process of getting the system in order.

The need to ensure all new hires completed pre-service requirements, demonstrated competency in job duties and long-term staff completed the required 16 hours of annual in-service training was discussed with Staff 1 (MC Administrator) on 10/26/22. She acknowledged the findings.

All employees identified in survey have completed required trainings and demonstrated compentancy. Documentation verifying training/compentencies is in place.

Auditing tools are now in place and Staffing Coordinator has been retrained on required training/compentancies and documentation needed for new employees.  

The Staffing Coordinator will give weekly reports to the Administrator.  Training/compentancies documentation will be reviewed weekly.  

The Staffing Coordinator and Administrator are responsible to see that the corrections are completed and monitored.   

Based on observation, 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 C252 and C270.

Refer to C252 and C270

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 and 3's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.  

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN) on 10/26/22. They acknowledged the findings.

Resident 2 and 3's Service Plan has been updated to include all missing fields identified in survey, specifically individualized nutrition and hydration status and needs.  

Person's responsible for Service Plans have been retrained on required componants of the Service Plan.

A sample of Service Plan will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs.

A monthly Service Plan report to be generated to determine due dates and ensure compliance.

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

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 2 of 3 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:

Resident 2 and 3's service plans offered some information about the resident's interests, but the facility had not fully evaluated the resident's:

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

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

There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.

Observations on 10/24/22 and 10/25/22 showed several small group activities being led by facility staff. Resident 2 spent most of his/her time seated at a table outside the group or walking the halls. Resident 2 had minimal participation in the group activities. Resident 3 was observed in three activities. When not engaged s/he would leave repeatedly to wheel around the halls.  

The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN) on 10/26/22. The staff acknowledged the findings.

Resident 2 and 3's Service Plan has been updated to include all missing fields identified in survey, specifically individualized activity plans.  

Person's responsible for Service Plans have been retrained on required componants of the Service Plan.

A sample of Service Plan will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs.

A monthly Service Plan report to be generated to determine due dates and ensure compliance.

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

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 5 sampled residents (#1) with documented behaviors. Findings include, but are not limited to:

Residents 2 and 3 were admitted to the facility in March 2020 and November 2021, respectively, with diagnoses including dementia.

Review of Resident 2 and 3's records, interviews with staff and observations of the residents between 10/24/22 and 10/26/22 were completed. The residents' records documented behaviors including anxiety, exit seeking, refusal of care and medications, combative with staff, kicking staff, sexually inappropriate comments, throwing items and aggression towards staff.

The residents' service plans, dated 03/09/22 and 08/29/22, respectively, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors.  

On 10/26/22, the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (MCC Administrator) and Staff 2 (LPN). The staff acknowledged the findings.

Resident 2 and 3's Service Plan has been updated to include all missing fields identified in survey, specifically individualized behavior plans.  

Person's responsible for Service Plans have been retrained on required componants of the Service Plan.

A sample of Service Plan will be audited monthly to ensure they are completed timely, include all required components and are reflective of resident current care needs.

A monthly Service Plan report to be generated to determine due dates and ensure compliance.

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