Print Inspection: WEZI

The findings of the change of ownership licensure survey, conducted 10/30/23 through 11/01/23, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

Abbreviations possibly used in this document:

ADL:activities of daily living

bid:twice a day

CBG:capillary blood glucose or

blood sugar

CG:caregiver

cm:centimeter

ED:Executive Director

F:Fahrenheit

HH:Home Health

LPN:Licensed Practical Nurse

MA:          Medication Aide

MAR:Medication Administration

Record

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 11/01/23, conducted on 03/01/24, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 staff (#s 7, 8 and 9) completed the required annual infectious disease prevention training. Findings include, but are not limited to:

Training records were reviewed on 10/30/23.

Staff 7 (MT), hired 01/09/20, Staff 8 (CG), hired 05/29/20, and Staff 9 (CG), hired 06/18/20, lacked documented evidence of completing the required annual infectious disease prevention training.

The need for all employees to complete annual training on infectious outbreaks and infection control was reviewed with Staff 1 (ED) on 10/31/23. She acknowledged the findings.

Staff upon starting on the floor will complete Oregon Care Partners infection control training and annually according to state law.

Monthly audits will be done to ensure staff has completed Infector control training

Monthly

Executive Director.

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

Observations of the facility on 10/30/23 and 10/31/23 revealed the following:

* Multiple resident rooms and common bathrooms had scraped doors and/or jambs;

* The transition pieces in the activity area between the laminate flooring and carpet were unsecured and separated from the floor;

* The carpet throughout the facility was stained, ripped, separated, and fraying; and

* The legs of dining room chairs were chipped and damaged.

The surveyor toured the environment with Staff 1 (ED) on 10/30/23. She acknowledged the above areas needed to be cleaned and repaired.

Chairs in dining room will be sanded and re-stained. Doors and trim puttied and stained. Repairs to patch carpet will be made and carpet shampooed.

Monthly audits will be done to see if new repairs are needed.

Monthly

Enviromnental services

Based on observation and interview, it was determined the facility failed to provide a one way flow of soiled items from the soiled area to the clean area in order to preclude the potential for contamination of clean linens and clothing. Findings include, but are not limited to:

The facility laundry room was toured with Staff 1 (Ed) and Staff 3 (RCC) on 10/31/23. Observation of the laundry room, designed to be used for processing soiled laundry, identified there was not a one way flow of soiled items.

Baskets of laundry and bags of soiled laundry were on the floor throughout the laundry room. There was no clearly identified flow from dirty to clean for laundry processing.

The need to ensure the one way flow of soiled laundry was discussed with Staff 1 and Staff 3 on 10/31/23. They acknowledged the findings.

Resident laundry will not be stored in laundry room. Laundry room will be clearly marked with clean side and dirt side.

Staff training on proper use of the hoper and making the expectation that everyone hopper stuff right away and not leav it it for someone else to clean.

Staff training and retraining when new staff come on.

Weekly audits and retraining with new staff come on.

RCC & Environmental Services

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 374, C 513, and C 530.

refer to C 374, C 513, and C 530

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 6, 10 and 11) had documentation of completed pre-service orientation, pre-service dementia training, and demonstrating competency in all required areas within 30 days of hire. The facility failed to ensure 3 of 3 sampled staff (#s 7, 8, and 9) completed 16 hours of annual in-service training. Findings include, but are not limited to:

Staff training records were reviewed on 10/30/23 and 10/31/23.

a. Staff 6 (MT), hired 04/23/23, lacked documented evidence of completing required pre-service orientation prior to beginning job duties, including:

* Resident Rights and Values of CBC;

* Infectious Disease Prevention; and

* Fire safety and emergency procedures.

Staff 6, Staff 10 and Staff 11 (CGs) hires 05/13/23 and 06/13/23 respectively, lacked documented evidence of completing required pre-service dementia training prior to beginning job duties, including:

* Techniques for understanding, communicating and responding to distressful behavioral symptoms; including but not limited to, reducing the use of antipsychotic medications for non-standard uses when responding to distressful behavioral symptoms.

* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to:

-Identify and address pain;

- Provide food and fluid;

- Prevent wandering and elopement;

-Use a person-centered approach.  

* Family support and the role the family may have in the care of the resident.

* How to recognize behaviors that indicate a change in the residents' condition and report behaviors that require on-going assessment;

* How to provide personal care to a resident with dementia, including an orientation to the resident and the residents' service plan, as required in OAR 411-054-0070(4). and

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

There was no documented evidence of Staff 6 demonstrating competence in all job duties within 30 days. Staff 6 had demonstrated competence with medication pass.

b. Staff 7 (MA), hired 01/20/20, Staff 8 (CG) hired 05/29/20, and Staff 9 (CG), hired 06/18/20, lacked evidence of 16 hours of annual in-service training.

The need to ensure staff completed all required pre-service orientation and training, demonstrated competence with in 30 days, and completed annual training was discussed with Staff 1 (ED) on 10/30/23 and 10/31/23. She acknowledged the findings.

All staff before they start on the floor will complete all training according to state rules. New Relias coursed changed added to monthy training.

Relias courses added or changed to meet state laws.

Monthly audits will be done to make sure all staff are completing Relias as assigned.

Executive Director

Based on observation and interview, it was determined the facility failed to ensure courtyard fencing was constructed to reduce the risk of resident elopement, and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement. Findings include, but are not limited to:

A tour of the facility courtyard on 10/30/23 revealed the fencing around the perimeter of the secured outdoor area was found with loose dirt and large gaps at the bottom in several areas.  

There were two patio chairs and two benches which were easily moveable and not of sufficient weight or design to prevent potential elopement.

The need to ensure outdoor courtyard fencing was constructed to reduce the risk of resident elopement and furniture in the outdoor recreation area was of sufficient weight and design to prevent resident injury or aid in elopement was discussed with Staff 1 (ED) and Staff 4 (Director of Environmental Services) on 10/31/23. They acknowledged the findings. The facility addressed the issues prior to the end of the survey.

Bricks were placed under fence where dirt has eroded or washed away. Door times for unlocking were adjusted and Maintenance was added so he can adjust doors when he is working out side. Sand bags where re-attached to chairs that were missing.

audits will be done quartely to check for gaps, the chairs are weighted down,

Quartely

Environmental Services