Print Inspection: SW9T

The findings of the re-licensure survey, conducted 10/16/23 through 10/19/23, 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 revisit to the re-licensure survey of 10/19/23, conducted 01/10/24 through 01/11/24, 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.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to have medical and other records kept confidential. Findings include, but are not limited to:

1. During an interview on 10/18/23 at 8:30 am, Staff 8 (Lead Chef) stated resident diet information was tracked using the "Resident Menu Directory" available on staff members' personal cell phones. Survey reviewed the electronic document on Staff 8's personal cell phone. The document contained residents' photos, full names, and diet preferences or needs.

2. During an interview on 10/18/23 at 1:00 pm, Staff 7 (MT) provided information regarding Resident 6's service plan and care needs. Observations made on 10/18/23 at 1:20 pm revealed an unsampled resident inquired about the contents of the interview, and Staff 7 provided personal information regarding Resident 6 to the unsampled resident.

The need to ensure the facility kept residents' medical and other records confidential was discussed with Staff 1 (Community Manager) and Staff 5 (LPN) on 10/19/23. They acknowledged the findings.

OAR 411-054-0027 Resident Rights and Protection

1.) The following action(s) are being taken to correct violations, per each example given:

a. Resident Menu Directory has been removed from all staff personal phones. A diet binder has been created for each house. Training was provided to the staff #7 that was present during the survey on the policy and procedure for keeping residents' private health information confidential.

2.) This system will be corrected as follows:

a. All employees will receive training on the policy and procedure for keeping resident private health information confidential.

3.) This system will be evaluated as follows:

a.The area needing correction will be evaluated on a monthly basis.

4.) The Community Manager or designee  will be responsible to ensure the corrections are completed/ monitored.      

Based on interview and record review, it was determined the facility failed to report an incident to the local Seniors and People with Disabilities (SPD) office, if abuse or neglect could not be ruled out, for 1 of 1 sampled resident (#2) with a documented medication error. Findings include, but are not limited to:

Resident 2 moved into the facility in 03/2023 with diagnoses including Alzheimer's disease, dementia and insomnia.

Review of the resident's record, including progress notes and incident reports, identified the following:

A review of the facility's incident report dated 09/16/23, noted at 7:30 pm the MT had dispensed Resident 2's medication and an unsampled resident's medication into medication cups that were placed on the medication cart next to each other. At 8:15 pm, the MT proceeded to give Resident 2 one of the medication cups from the medication cart and walked away to wash her hands. The MT failed to confirm the label on the medication cup belonged to Resident 2.

On 09/16/23 at 8:15 pm, Resident 2 was administered the following medications that were prescribed for another resident:

* atorvastatin 40 mg (medication for high cholesterol);

* carbidopa levodopa 25-100 mg (medication for Parkinson's disease);

* tramadol 50 mg (medication for moderate to severe pain); and

* trazodone 50 mg (antidepressant and sedative).

A review of Resident 2's current physician orders identified s/he was not prescribed any of the above medications and was not diagnosed with high cholesterol, Parkinson's disease or severe pain.

As a result, Resident 2's physician instructed the MT to hold Resident 2's prescribed melatonin medication.

This represented an incident where the facility failed to protect a resident, was considered neglect and needed to be reported to the local SPD office immediately.

There was no documented evidence the facility reported the incident to the local SPD office as required.

The facility was asked to report the medication error to the local SPD office on 10/16/23. On 10/17/23 Staff 1 (Community Manager) provided verification of the self report.

The need to immediately report incidents of suspected abuse or neglect to the local SPD office was discussed with Staff 1 (Community Manager) and Staff 5 (LPN) on 10/16/23. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting and Investigating Abuse-Other Action

1.) The following action(s) are being taken to correct violations, per each example given:

a. Resident #2 - Facility self-reported incident that occurred on 9/16/23, to local SPD prior to survey exit, on 10/19/23.  

2.) This system will be corrected as follows:

a. All employees will complete "Elder abuse

Prevention, Investigation and Reporting" provided by Oregon Care Partners,

b. Facility will review incident reports daily, during morning stand-up, to ensure all incidents are investigated & reported appropriately (when abuse and neglect cannot be ruled out, for injuries of unknown cause, & all instances of abuse & neglect or suspected abuse & neglect) to local SPD.

c. Facility administrator will review, sign, & date all incident reports.

3.) This system will be evaluated as follows:

a. Facility Administrator & Facility LN will coordinate  at least once monthly during Quality Improvement meetings to ensure that all staff have completed the required pre-service & on-going training 'Abuse & Reporting Requirements.'

4.) The Community Manager or designee  will be responsible to ensure the corrections are completed/ monitored.

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

The facility's kitchens and dry storage areas were toured from 10/16/23 to 10/19/23 and the following was identified:

1. Helens House kitchen:

a. An accumulation of food spills, splatters, grease, loose food debris, dirt, and dust was observed on, in and/or underneath the following:

* Waffle iron in the cupboard below the microwave;

* Cabinet fronts, sides, and interiors;

* Refrigerator vent;

* Window, window ledge, and blind above sink;

* Air conditioner above sink; and

* Ceiling, fans, and ceiling track lighting.

b. Observation of the refrigerator and cupboards revealed the following foods were not dated, and/or labeled appropriately:

* Clam base;

* Squeeze bottle in cupboard with unidentified contents;

* Biscuit mix; and

* Brown sugar.

c. Meal preparation and service were observed on 10/16/23 and 10/17/23 and the following was identified:

* Staff 6 (MT) had fingernail polish on, without gloves, while preparing food;

* Staff 11 (Chef) did not rinse/wash tomatoes, cucumbers, romaine lettuce, honeydew melon, cantaloupe, and pineapple prior to cutting and serving to residents; and

* There were no alcohol swabs available for staff to use on temping thermometers.

d. Staff were observed cleaning the kitchen after meal service and the following was identified:

* There was no method for sanitizing knives, pots, or pans; and

* The steel wool scrubber used for pots and pans was falling apart and had large food particles trapped in it.

e. A line of ants was observed on the cabinet frame to the left of the garbage can.

f. The exit door in the kitchen area lacked weather stripping creating an open gap between the door and the frame.

2. Helens House food storage:

a. An accumulation of food spills, splatters, loose food debris, dirt, dust, cobwebs, and dead bugs was observed on, in and/or underneath the floors, ceilings, walls, refrigerators, freezers, food storage shelving, and air conditioner.

b. The garbage can had no lid.

c. There was a two inch by two inch open gap between the garage door and floor, where the dry storage was kept.

d. The window had a five inch by eight inch piece of cardboard next to the air conditioner, creating a large gap to the outside.

3. Rainier House kitchen:

a. An accumulation of food spills, splatters, grease, loose food debris, dirt, and dust was observed on, in and/or underneath the following:

* The microwave;

* Cabinet fronts, sides, and interiors;

* Refrigerator vent;

* The oven interiors;

* Window, window ledge, and blind above sink;

* Air conditioner above sink; and

* Ceiling, fans, and ceiling track lighting.

b. Observation of the refrigerator revealed the following foods were not dated, and/or labeled appropriately:

* An unidentified red liquid; and

* Two bags of food.

c. Meal service and cleanup were observed on 10/17/23 at 8:30 am and the following was identified:

* Staff 9 (MT) was serving food to residents without an apron and transported food to a resident's room without covering it; and

* The steel wool scrubber used for pots and pans was falling apart and had food particles trapped in it.

d. The oven door was separated from the main panel on the top right side.

e. There was a one inch by one inch circular hole in the countertop and a half inch gap between the soap pump base and the countertop.

f. The exit door in the kitchen area lacked weather stripping creating an open gap between the door and the frame.

4. Rainier House food storage:

a. An accumulation of food spills, splatters, loose food debris, dirt, dust, cobwebs, and dead bugs was observed on, in and/or underneath the floors, ceilings, walls, refrigerators, freezers, food storage shelving, and air conditioner.

b. Fruit flies were observed above the produce on the metal shelves.

c. Molding produce was observed on the metal shelves and in one of the produce refrigerators. The survey team requested the facility inspect and remove any molding produce prior to survey exit.

The kitchens and food storage areas were toured with Staff 1 (Community Manager) 10/19/23, and the need to ensure the areas were clean and food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed. She acknowledged the findings.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

1.) The following actions will be taken to correct the violations for each example given:

Helen's House Kitchen:

The following areas in the kitchen will be addressed immediately:

a. Interior and exterior of all cabinets and drawers; refrigerator vent; window, window ledge, and blind above sink; air conditioner above sink; ceiling fans and ceiling track lighting.

b. All open food items will have open dates and labels.

c. All staff will be required to have further training on appropriate infection control prevention and food sanitation.

d. Alcohol wipes are available in the kitchen to sanitize food thermometers after temping the food.

e. All pots and pans will be sanitized in the dishwasher.

f. Steel wool scrubbers will no longer be used in the kitchen.

g. Community will schedule third party pest control to come on site to assist with the ant issue and then will continue with their routine visits.

h. Weather stripping on the kitchen exit door will be replaced.

Helen's Dry Food Storage Area

The following areas in the kitchen will be addressed immediately:

a.  This area will be deep cleaned to ensure that there is not any food debris, dirt, dust, cobwebs and/or dead bugs present.

b. Garbage can with a lid has been ordered.

c. 2 inch gap between the garage door and the floor will be fixed.

d. air conditioner will be removed from the window.

Rainier House Kitchen:

The following areas in the kitchen will be addressed immediately:

a. Microwave; Cabinet fronts, sides and interiors; refrigerator vent; interior of ovens; window, window ledge, and blind above sink; air conditioner above sink; ceiling, fans, and ceiling track lighting.

b. All open food items will have open dates and labels.

c.  All universal workers will wear required aprons when serving food, and will be required to have further training on appropriate infection control prevention and food sanitation.

d. Facility will ensure all meal trays are covered appropriately when food is being delivered to rooms.

e. Steel wool scrubbers will no longer be used in the kitchen.

g. One inch by one inch circular hole in the counter top and half inch gap between the soap pump base and the counter top will be repaired.

h. Weather stripping on the kitchen exit door will be replaced.

Rainier Dry Food Storage Area

The following areas in the kitchen will be addressed immediately:

a. This area will be deep cleaned to ensure that there is not any food debris, dirt, dust, cobwebs and/or dead bugs present.

b.  Community will schedule third party pest control to come on site to assist with the fruit flies and then will continue with their routine visits.

2.) This system will be corrected as follows:

a. Facility will implement daily, weekly, & monthly cleaning checklists to ensure all areas of the kitchen are clean & in good repair.

b. All chefs will be required to have further training on 'Infection Control in the Kitchen' & 'Proper Food Storage.'  

c. All Universal workers will have on-going training on 'Infection Control in the Kitchen'

3) This system will be monitored as follows:

a. Facility Dietary Manager will ensure that the daily, weekly, & monthly cleaning checklists are completed. Dietary manager will bring all cleaning checklists to monthly quality improvement meetings to discuss concerns or areas of the kitchen that need repair.

b. Facility Administrator will review all staff training at least once monthly and with each new-hire orientation to ensure appropriate training is completed.

c. Facility Administrator and dietary manager will complete once weekly walk-throughs of the kitchen to ensure all food is stored safely, and the kitchen is clean & in good-repair.

4.) Facility Administrator and facility dietary manager will be responsible for ensuring completion and monitoring on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure changes of condition had resident-specific instructions or interventions developed, progress was documented weekly until resolution and changes of condition were referred to the RN as appropriate for 1 of 3 sampled residents (#2) who were reviewed with changes of condition. Findings include, but are not limited to:

Resident 2 moved into the facility in 03/2023 with diagnoses including Alzheimer's disease and dementia.

Interviews with staff, review of Resident 2's progress notes and temporary service plans (TSP's) dated 08/01/23 through 10/16/23, and incident investigations were completed during the survey.

a. The following short term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and progress noted at least weekly through resolution:

* 08/20/23 progress note -"monitor behaviors each shift, 2x/shift";

* 08/29/23 incident report- injury fall with small abrasion to left knee";

* 09/08/23 progress note- behavior; and

* 09/09/23 progress note- behavior.

b. The following changes of condition lacked referral to the facility RN for further assessment:

* 08/20/23 TSP- "Increase in care assistance needed" (incontinent care and dressing/undressing); and

* 09/09/23 TSP- "Toileting and brief changes."

During an interview on 10/16/23, Staff 6 (MT/CG) stated Resident 2 had a decline and continued to need toileting assistance and assistance with dressing in the morning and at night time.

During an interview with Staff 1 (Community Manager) and Staff 5 (LPN) on 10/17/23, they confirmed Resident 2 was previously independent with toileting, changing incontinent briefs and dressing. They further confirmed the increase in care needs was ongoing.

The decline in ADL ability was considered a significant change of condition that required referral to the facility RN for further assessment.

There was no documented evidence the facility referred the increase in care needs to the facility RN.

The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, changes of condition were monitored through resolution and significant changes of condition were referred to the RN, as appropriate was discussed with Staff 1 and Staff 5 on 10/18/23. They acknowledged the findings.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring:

1.) The following actions are being taken to correct violations per each example given:

a. Resident #2 - Facility LN will begin weekly significant change of condition assessments for resident #2. Facility LN will assess behaviors and decline in ADL ability. Facility LN will include interventions and clear instructions for staff to follow via TSP/ISP. Facility LN will continue to monitor and assess resident weekly, until resident is back to baseline or LN can reasonably establish a new baseline.

2.) This system is being corrected as follows:

a. Facility is implementing a 24 hr audit/process to ensure that all resident changes of condition are evaluated at onset, that appropriate interventions are put in place via TSP/ISP, & that all changes of conditions are monitored until resolved. The 24hr audit/process will include a lookback of the last 24hrs (or 72 hrs on Mondays) of chart notes, incident reports, alert log, and reviewing the 24hr binder. This audit will ensure that all appropriate care paths are followed in a timely manner. The 24hr audit and findings will be brought to daily stand-up for review.

b. Facility will ensure that a skin log & significant change of condition log is maintained in the 24hr binder to ensure appropriate oversight, interventions, and communication to staff.

c. Facility staff will receive training related to the 24hr process and will include ensuring all skin events, or changes of condition are added to either the skin log or the significant change of condition log.

d. Facility nurse will review the skin log, significant change of condition log, and resident alerts, daily during morning stand-up. LN will also ensure that all new skin events and/or treatments are entered into the resident's chart with clear instructions for staff to follow.

e. Facility nurse will ensure that all interventions and/or staff instructions secondary to change of condition are implemented via TSP/ISP and made a part of the resident's record.

3.) This system will be evaluated as follows:

a. The 24hr audit will be completed and reviewed daily, during morning stand-up, and a 72 hr audit will be completed and reviewed on Mondays (or upon return from 2 days off.)

b. Facility LN will review skin log and change of condition log, daily, and will provide once weekly resident assessments with weekly documentation, until resolved.

c. Facility will ensure that all TSPs/ISPs (temporary service plans) are made a part of the resident's service plan/evaluation as they are updated per scheduling requirements: Initial, within 30 days of admission, quarterly thereafter, & with significant change of condition or readmission.

d. Facility Administrator will ensure that all applicable staff (those writing, reviewing, and updating TSPs/Service plans) will have on-going training as required. Facility administrator will review training grid at least once monthly, and with each new-hire orientation, as applicable.

e. Facility Administrator will ensure that the 24hr audit and review is done daily, and reviewed during morning stand-up.

4.) The facility administrator, and the facility LN will be responsible to ensure correction and oversee ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who experienced significant changes of condition were assessed by the RN and/or the assessments were completed in a timely manner and included findings, resident status, and interventions made as a result of the assessment, and updated the service plan for 1 of 1 sampled resident (#2) who experienced a significant change of condition. Findings include, but are not limited to:

Resident 2 moved into the facility in 03/2023 with diagnoses including Alzheimer's disease and dementia.

During the acuity interview on 10/16/23, Staff 8 (MT/CG) reported the resident had a decline related to needing more care assistance with incontinent care, toileting, and dressing in the morning and at night time.

Review of the 08/01/23 through 10/16/23 progress notes, service plan, temporary service plans (TSP's), and weight records identified the following significant changes of condition:

a. Temporary Service Plans identified the following significant change of condition:

* 08/20/23 - "Increase in care assistance needed" (incontinent care and dressing/undressing); and

* 09/09/23 - "Toileting and brief changes."

During an interview with Staff 6 (MT/CG) on 10/16/23, Resident 2 had a decline and continued to need toileting assistance and assistance with dressing in the morning and at night time.

During an interview with Staff 1 (Community Manager) and Staff 5 (LPN) on 10/17/23, they confirmed Resident 2 was previously independent with toileting, changing incontinent briefs and dressing. They further confirmed the increase in care needs was ongoing.

The decline in ADL ability was considered a significant change of condition that required a timely RN assessment.

There was no documented evidence an RN assessment that included findings, resident status, and interventions made as a result of the assessment, had been completed after the significant decline in ADL ability.

b. Weight records identified the following:

06/03/23 - 116.0 pounds;

07/02/23 - 116.0 pounds;

08/02/23 - 114.4 pounds;

09/02/23 - 107.0 pounds; and

10/18/23 - 112.4 pounds (observed weight taken during survey).

From 06/03/23 through 09/02/23, Resident 2 lost nine pounds or 7.758% total body weight within three months.

This was considered a severe weight loss that required a timely RN assessment and a review and update to the service plan within 48 hours.

Observations of lunch meal service on 10/16/23-10/18/23, Resident 2 was able to eat independently and consumed 100% of each meal.

Staff 2 (RN) completed an RN assessment on 09/12/23 and a TSP was initiated with weight loss interventions. On 09/18/23 weekly weight monitoring for four weeks, was added to the MAR.

During an interview on 10/17/23, Staff 2 (RN) and Staff 5 (LPN) reported the facility took all resident monthly weights from the first of the month through the sixth of the month. The following week Staff 4 reviewed the weight reports and would begin scheduling individual resident assessments for those that were identified with significant weight loss. Staff 4 stated that is why the assessment and TSP was done on 09/12/23.

The need to ensure an RN assessment was completed in a timely manner, included documentation of findings made, resident status, and interventions and the service plan reviewed and updated within 48 hours was discussed with Staff 1 and Staff 5 on 10/18/23. They acknowledged the findings.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services:

1.) The following actions are being taken to correct violations for each example given:

a. Resident #2 - Facility LN will begin weekly significant change of condition assessments for resident #2. Facility LN will assess behaviors and decline in ADL ability. Facility LN will include interventions and clear instructions for staff to follow via TSP/ISP. Facility LN will continue to monitor and assess resident weekly, until resident is back to baseline or LN can reasonably establish a new baseline.

2.)This system will be corrected as follows:

a. Facility is implementing a 24 hr audit/process to ensure that all resident changes of condition are evaluated at onset, that appropriate interventions are put in place via TSP/ISP, & that all changes of conditions are monitored until resolved. The 24hr audit/process will include a lookback of the last 24hrs (or 72 hrs on Mondays) of chart notes, incident reports, alert log, and reviewing the 24hr binder. This audit will ensure that all appropriate care paths are followed in a timely manner. The 24hr audit and findings will be brought to daily stand-up for review.  

b. Facility is reviewing & updating the weight tracking system to ensure appropriate oversight & timely assessment. This will be done in the EHR system, Point Click Care. Facility RN will run the weight(s) report at least once weekly, to identify significant weight loss/gain.

c. Facility administrator will review assessment logs once weekly to ensure all changes of condition and nursing assessments are being completed timely, thoroughly, and with all required components.  

3.) This system will be evaluated as follows:

a. The 24/72 hr audit will be completed daily (5 days a week, and 72 hr audit on Mondays, or upon return from 2 days off.)

b. Skin logs & change of condition logs will be reviewed daily during morning stand-up, which will include facility nurse(s).

c. Weight tracking reports will be ran at least once weekly, in an attempt to identify any significant weight gain/loss.

d.To ensure ongoing compliance with nursing oversight and resident assessments', facility administrator will review all active assessments, at least once weekly.

4.) Facility Administrator and Facility RN will be responsible for ensuring completion and ongoing compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident and increased staffing levels to maintain adequate resident care and services when utilizing universal workers. Findings include, but are not limited to:

Observations, interviews, and record review, were conducted during the re-licensure survey.

During the entrance conference interview on 10/16/23 the following was identified:

* The facility had a licensed occupancy of 30 beds and had a current census of 22 residents;

* The facility consisted of two separate and distinct houses, Helens House and Rainier House, which had three levels in each house;

* Four residents required two person assist for transfers including assist with a lift device, incontinent care, bathing and emergency evacuation;

* Six residents required heavy care needs which included full assistance with all or most ADL's;

* 19 of the 22 residents had memory care diagnoses; and

* The facility employed universal workers whose duties included other tasks (e.g., laundry, food preparation, food service, activities, and medication management) in addition to direct resident care.

Observations between 10/16/23 and 10/18/23, identified one MT/CG was assigned to Helen's House and one MT/CG and one "float" CG was assigned to Rainier House. The float from Rainier was responsible to provide breaks for staff in Helens House and assist with two person care needs in both houses. The caregivers were observed providing medication management, meal preparation and service, housekeeping, kitchen tasks, activities and direct care.

During an interview on 10/18/23, Staff 1 (Community Manager) reported the facility staffed two 12-hour shifts. She confirmed the facility staffing plan for both shifts was one MT/CG in each house and one "float caregiver" that worked primarily in Rainier House and would float between both houses.

Review of the UDS (Uniform Disclosure Statement), the facility used Universal Workers (whose job duties included providing care and services to residents in addition to having other tasks, such as housekeeping, laundry and meal service.) The UDS indicated the facility staffing plan was as follows:

Rainier House 6:00 am to 6:00 pm 1 universal worker;

Helens House 6:00 am to 6:00 pm 1 universal worker;

6:00 am to 6:00 pm  and 1 float (universal worker);

Rainier House 6:00 pm to 6:00 am 1 universal worker;

Helens House 6:00 pm to 6:00 am 1 universal worker; and

6:00 pm to 6:00 am 1 campus float (universal worker).

During a group interview on 10/17/23, multiple non-sampled residents had concerns there was a lack of staff during the night shift that resulted in long call light response times.

Review of the call light report dated 10/04/23 through 10/18/23 identified on 42 occasions call light response times ranged from in excess of 15 minutes up to two hours.

The need to ensure a sufficient number of staff to meet the 24-hour scheduled and unscheduled needs of each resident, increased staffing levels to maintain adequate resident care and services when utilizing universal workers was discussed with Staff 1 and Staff 5 (LPN) on 10/18/23. They acknowledged the findings.

Refer to C 361.

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing:

1.) This following action is being taken to correct each violation per examples:

a.  Facility has adjusted staffing to meet the acuity based staffing tool.

b.  Facility has updated the required acuity based staffing tool, on The Departments' site to reflect the care needs of residents #1, 2, 3, 4 and 6.

c. Facility will run the report for staff call lights and will review call light times during stand up.

2.) This system is being corrected to eliminate future violations, as follows:

a. Facility maintenance director will audit & pull all call-times from the last 24hrs and will bring results to morning stand-up for review,

b. Facility Administrator will update the ABST at each evaluation (Initial, 30 day, quarterly) & with significant change of condition, to ensure adequate staff to meet the scheduled & unscheduled needs of the residents.

3.) This system will be evaluated as follows:

a. Facility administrator will update the ABST with each resident evaluation completed (initial, 30-day, quarterly) and with significant change of condition,

b. Facility administrator will review the staff schedule at least once monthly to ensure the schedule is reflective of the staffing requirements as based on the ABST,

c. The facility maintenance director will run & review resident call times at least daily (on work days) and will bring this report to daily stand-up.

4.) The Facility Administrator and Facility Maintenance Director will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to update an acuity-based staffing tool (ABST), based on the evaluated care needs for 5 of 5  residents (#s 1, 2, 3, 4 and 6), and the ABST failed to convert the evaluated care needs of the residents into staff hours that was used to generate a facility staffing plan that met the 24-hour scheduled and unscheduled needs of all residents. Findings include, but are not limited to:

On 10/18/23, Staff 1 (Community Manager) and the surveyor reviewed the ABST used by the facility and the staffing plan. The following was identified:

* The facility had not updated the ABST to reflect all evaluated care needs for five sampled residents; and

* The staffing hours generated by the ABST failed to meet the 24 hour scheduled and unscheduled care needs for Resident 2, 3 and one non-sampled resident who required two person care including transfers, bathing, incontinent care, escorts and emergency evacuation.

The need to ensure the facility updated the ABST to convert evaluated care needs of residents into staff hours needed to generate a facility staffing plan that included meeting the 24 hour scheduled and unscheduled needs of all residents was discussed with Staff 1 and Staff 5 (LPN) on 10/18/23. They acknowledged the findings.

Refer to C 360.

OAR 411-054-0037 (1-8) Acuity-Based Staffing Tool:

1.) The following action is being taken to correct each violation per examples given:

a. Facility has updated the required acuity based staffing tool, on The Departments' site to reflect the care needs of residents #1, 2, 3, 4 and 6.

b. Facility Community Manager and RCC will receive training related to ABST requirements, to ensure the

staffing schedule meets requirements.

2.) This system is being corrected to eliminate future violations, as follows:

a. Facility Community Manager and RCC will receive training related to the requirements of the Acuity-Based

Staffing Tool,

b. Facility will maintain ABST and update resident care needs in the ABST at time of each resident evaluation &/or with any significant change of condition

c. Facility Administrator will review staffing schedules to ensure that the schedule is reflective of staffing requirements based on the ABST.

3.) This system will be evaluated as follows:

a. Facility will update the ABST with each  resident evaluation: initial, 30-days, quarterly, and with significant change of condition,

b. Facility Administrator will review the monthly staffing schedule to ensure that schedule is reflective of staffing needed per the ABST at least once monthly.

4.) Facility Administrator and Facility RCC will oversee and ensure on-going compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted according to the Oregon Fire Code (OFC). Findings include, but are not limited to:

Fire drill records reviewed from April 2023 through September 2023 lacked the following:

* Documented evidence the facility provided fire and life safety instruction for staff on alternating months of the fire drills;

* Documented evidence fire drills were conducted every other month;

* Evidence alternate escape routes were used; and

* Evidence of immediate changes that were made for the residents who were identified as unwilling to participate in the fire drills, to ensure the evacuation standard could be met.

On 10/16/23 the need to ensure fire drills were conducted every other month, included all required components and fire and life safety instruction for staff occurred on alternate months of the fire drills was reviewed with Staff 1 (Community Manager) and Staff 3 (Facilities Director). They acknowledged the findings.

OAR 411-054-0090 (1-2) Fire & Life Safety: Safety

1.) The following actions are being taken to correct each violations per examples given:

a. Facility will conduct unannounced fire drills every other

month at different times of the day, evening and night. No less than 2 of each shift (day/evening/night) annually.

b. Fire and life safety instruction for staff will be provided on alternate months.

c. Community will implement a fire drill tool that

encompasses all required pieces including but not limited to; evacuation time period needed, alternative exit routes used, staff and residents that participated in fire drill and interventions and resolution related to resident evacuation concerns identified during fire drills.

2.) This system is being corrected to eliminate future violations, as follows:

a. Facility Maintenance director is receiving updated training on the requirements for Fire & Life Safety; Fire Drills & on-going training,

b. Facility Maintenance director will conduct all fire drills and on-going training as required by regulations

c. All documentation related to fire-drills & fire & life instructions/trainings, will be filed in the 'Fire Drill/Fire & Life Safety binder, and will be filed by month,

d. Facility administrator will review & audit Fire & Life Safety Binder, to ensure compliance.

3.) This system will be evaluated as follows:

a. All fire drills and fire & life safety training will be reviewed on a monthly basis.

4.) The Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to ensure outdoor perimeter fencing was not secured in a way that prevented exit unless the RCF had written approval from the Department. Findings include, but are not limited to:

Observation of the front entrance pedestrian gate on 10/18/23 revealed it was secured with a combination coded bike lock.

During an interview on 10/19/23 with Staff 3 (Facilities Director) it was reported the lock was going to be changed to a keyed locking system because residents were having trouble with the number combination lock.

On 10/19/23, the surveyor requested Department approval that allowed the RCF facility to secure the gate. Staff 3 stated, to his knowledge, the facility had not been given Department approval.

The need to ensure perimeter fencing and gates were not secured to prevent exit was discussed with Staff 1 (Community Manager) on 10/19/23. She acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior:

1.) The following actions are being take to correct each violation, per the examples given:

a. Per approval from the policy analyst lock has been replaced on the pedestrian gate and code to lock has been posted on the inside and outside of the gate

2.) The following corrections are being made to eliminate future violations:

a. Facility maintenance director will check to ensure that the code to the lock on the pedestrian gate  is posted on the inside and outside of the gate during the weekly environmental walk through.

3.) This system will be evaluated as follows:

a. Facility Maintenance Director & Facility Administrator will conduct once weekly audits to ensure that the code to the lock on the pedestrian gate is posted on the inside and outside of the gate.

4.) Facility Maintenance Director & Facility Administrator will oversee and ensure on-going compliance.

Based on observation, interview, and record review, 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 between 10/16/23 and 10/19/23 and the following was identified:

1. Helens House:

The following items/areas inside and outside of the building were observed in need of cleaning and/or repair:

* Four basement ceiling lights were not operable;

* The brown couch in the basement had several dark stains;

* The carpet in front of the elevator had large dark stains;

* There were long boards with nails sticking out of them on a table in the basement;

* Two outlet covers under the countertop on the second floor were broken/chipped;

* The window ledges on the second floor were stained and had a rough surface;

* The linoleum floors on the second floor had black matter buildup and large scratches;

* The air conditioner in the living room on the second floor had a knob missing and dust/dirt/debris in the grill and vent;

* The ceiling and track lighting on the second floor had dust and cobwebs;

* Multiple areas of siding and corners of the building were cracked and/or had dry rot;

* There were cigarettes, a bed frame, and other large items in poor repair in front of the basement entrance; and

* The window had a five inch by eight inch piece of cardboard next to the air conditioner, creating a large gap to the outside.

2. Rainier House:

The following items/areas inside and outside of the building were observed in need of cleaning and/or repair:

* The basement window had a gap between the window and the air conditioner;

* The door to the exterior in the basement had chipped paint;

* Multiple pieces of furniture in the basement needed cleaning and/or were not useable;

* One window in the basement had a bent screen;

* The carpet in front of the elevator in the basement had large stains;

* There was a large unfinished patch of drywall on the ceiling on the first floor;

* The window ledges on the first and second floors were stained and had a rough surface;

* The linoleum floors on the second floor had large scratches and a sticky coating; and

* Multiple areas of siding and corners of the building were cracked and/or had dry rot.

The facility was toured and the areas/items needing cleaning and/or repair was discussed with Staff 1 (Community Manager) at 10:00 am on 10/19/23. She acknowledged the findings.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors:

1.) The following action is being taken to correct each violation per examples given:

a. Facility Maintenance Director is working on all environmental deficiencies in Helen's House and Rainier House.

b. Maintenance Director is working down the list of environmental deficiencies in order of priority.

2.) This system is being corrected to eliminate future violations as follows:

a. Facility has created new procedures for environmental walk-throughs, in an attempt to identify areas that need  immediate attention.

b. Facility Maintenance Director & Facility Administrator will document findings on the weekly environmental checklist. This document will have an area for goal of

completion.

c. Facility environmental walk-through checklist

will be reviewed once a week during stand up to ensure follow up.

3.) This system will be evaluated as follows:

a. Facility Maintenance Director & Admin will conduct environmental walk-throughs at least once weekly,

b. Environmental walk-through checklist will be reviewed at least once a week during stand up to ensure follow up.  

4.) Facility Administrator & Facility Maintenance Director will oversee and ensure on-going compliance.

Based on observation and interview, it was determined the facility failed to maintain hot water temperatures in residents' units within a range of 110 to 120 degrees Fahrenheit. Findings include, but are not limited to:

The building was toured on 10/18/23 and temperatures in resident units 1A and 1C were measured at 105 and 92 degrees Fahrenheit, respectively. During an interview with Staff 4 (Maintenance Coordinator) at 2:40 pm on 10/18/23, the above temperatures were confirmed and Staff 4 stated he had ongoing issues with water temperatures.

The need to ensure hot water temperatures in resident units were maintained within a range of 110 to 120 degrees Fahrenheit was discussed with Staff 1 (Community Manager) on 10/19/23. She acknowledged the findings.

OAR 411-054-0200 (9) Plumbing Systems:

1.) The following action is being taken to correct each violation per examples given:

a. Resident's units 1A and 1C water temperatures have been adjusted to meet the requirement.

2.) This system is being corrected to eliminate future violations as follows:

a. Facility Maintenance Director will check water temperatures at least once a week and adjust temperatures as needed to ensure that they meet the requirement.

3.) This system will be evaluated as follows:

a. Facility Maintenance Director will check water temperatures at least once a week and adjust temperatures as needed to ensure that they meet the requirement.

b. Water temperatures will be reviewed at least once a week during stand up to ensure follow up.

4.) Facility Administrator & Facility Maintenance Director will oversee and ensure on-going compliance.