Holly Residential Care Center

The findings of the re-licensure survey, conducted 06/01/22 through 06/02/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the re-visit survey to the re-licensure survey on 06/22/22, conducted 08/16/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 06/02/22, conducted 06/14/23, 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 and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:On 06/01/22 at 9:20 am, the facility's kitchen was observed to need cleaning or repair in the following areas:* Floors throughout the kitchen, including dry storage, had black matter build-up and food debris in corners, around perimeter edges and under equipment;* Sections of linoleum under the refrigerator/freezer units and near the ice machine were separating and pulling apart at the seams or edges. The area under the back sink was lifting away from the drain and had a long slit to the side. Several dark orange/brown areas of various sizes were noted on the linoleum;* Shelving and drawers throughout the kitchen and dry storage had food spills, white/gray accumulation, dust, and/or debris; * Ceiling vents had an accumulation of lint and dust on the grates;* Spills, splatters and/or debris were noted on the front of the ovens, backsplash behind the blender, fronts of refrigerators and freezers, sides of the ice machine and along the edges under the ice machine door;* Chipped laminate edges with exposed wood were noted on the lower shelves at the front of the kitchen;* Spills and debris were covering a package of bottled water and on multiple container lids;* Chipped wall edges with missing pieces were noted in multiple areas; * One section of the hood vents over the stove was noted with a substantial layer of grease and dust accumulation;* Multiple ceiling lights had dead insects and debris inside; and* Doors, door frames, ceiling and walls had splatters and spills.The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (Administrator), Staff 4 (Maintenance Director) and Staff 7 (Kitchen Manager) on 06/01/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents with a change of condition were evaluated and resident-specific instructions or interventions were developed and implemented for 1 of 2 sampled residents (#1) who experienced short term changes related to skin injury. Findings include, but are not limited to: Resident 1 was admitted to the facility in May 2018 with diagnoses including diabetes, obesity and edema.Observations of the resident, interviews with staff and review of the resident's 05/18/22 service plan, 03/01/22 through 05/31/22 progress notes, physician communications and incident investigations were completed. The resident was noted to be alert and oriented, required extensive assistance with all ADL care, utilized a Hoyer lift for transfers and an electric wheelchair for mobility. The resident had significant edema around the torso, thighs and feet, fragile skin and no recent history of falls.* On 03/12/22 nursing staff noted two open areas on the resident's bottom that did not appear as pressure injuries;* On 03/23/22 nursing staff noted a red circular bruise to the resident's cheek;* On 04/28/22 nursing staff noted swelling and an abscess to the resident's genital area;* On 05/01/22 nursing staff noted a new skin tear to the right upper front thigh;* On 05/03/22 nursing staff noted a light purple bruise to the top of the resident's right foot;* On 05/10/22 nursing staff noted multiple toes on the right foot had red marks;* On 05/20/22 nursing staff noted the resident's right hand was swollen; and* On 05/31/22 nursing staff noted a circle abrasion to the left upper hip. There was no documentation in the resident's record the facility had completed thorough investigations of the skin conditions/injuries to determine the cause, minimize reoccurrence, develop and implement interventions and to re-evaluate existing interventions for appropriateness and effectiveness. In interviews on 06/01/22 and 06/02/22 the resident indicated s/he had no concerns with his/her care. The resident denied any mistreatment by staff or physical incidents with other residents. The resident further indicated s/he had not experienced any falls, two staff assisted him/her with the Hoyer lift, s/he prefers to stay up in the wheelchair as much as possible and that the staff treat him/her well. In interview on 06/02/22, Staff 10 (RN) acknowledged there was no documentation of investigations related to the resident's injuries. Staff 10 indicated the resident was very vocal and able to let them know if something occurred. Staff 10 further indicated they believed the majority of the resident's skin issues were related to a combination of the edema, fragile skin, excess moisture, the Hoyer sling and shear during transfers. She understood their process and investigations needed to be documented. The need to ensure actions or interventions were determined and documented when a resident experienced a short-term change of condition was discussed with Staff 2 (Owner/RN). She acknowledged the findings. No further information was provided.

Based on interview and record review, it was determined the facility failed to conduct and document fire drills every other month, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of fire and life safety records from 01/01/22 through 05/31/22 identified the following deficiencies:There was no documented evidence the facility conducted fire drills every other month, as required.In an interview on 06/02/22, Staff 5 (Admin/Office Staff) stated "We don't have any documentation of fire drills. I don't think we've done one in the last year."On 06/02/22, the need to conduct and document fire drills every other month, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 2 (Owner/RN) and Staff 4 (Maintenance director). No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure they had an alternate fire drill plan which was written and signed by the local fire authority and had been submitted to the Department. This is a repeat citation. Findings include, but are not limited to:Fire drill records were reviewed on 08/16/22. Fire drill forms did not indicate how many residents had been evacuated.In an interview with Staff 1 (Administrator) and Staff 2 (Owner/RN) on 08/16/22 at 12:07 pm, Staff 2 stated they "never evacuated residents outside" during fire drills. She reported the Fire Marshal had approved sheltering-in-place when the facility was opened. The surveyor requested a copy of the Fire Marshal's written approval for sheltering in place; Staff 2 stated they did not have written approval, it had been approved verbally.Staff 2 reported in the same interview the facility had a fire inspection scheduled for 08/17/22 and could obtain written approval at that time. Staff 1 indicated she would write a plan for approval and obtain a signature.On 08/17/22 at 1:00 pm, the survey team indicated to Staff 2 the facility would have 48 hours to provide the Department with a shelter-in-place plan signed by the Fire Marshal. Staff 2 acknowledged if the plan was not provided to the department within 48 hours, the facility would remain out of compliance with the fire and life safety rule.No additional information was provided by the facility.

Based on interview and record review, it was determined the facility failed to provide fire safety instruction for residents, at least annually, in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to:Review of fire and life safety records indicated the following deficiencies:There was no documented evidence the facility provided annual fire safety instruction for residents, as required.On 06/02/22 the need to provide and document annual fire safety instruction for residents, in accordance with the OFC was discussed with Staff 1 (Administrator), Staff 2 (Owner/RN) and Staff 4 (Maintenance Director). No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in good repair. Findings include, but are not limited to:During a tour of the facility on 06/01/22 at 9:00 am the following areas were found in need of repair:* Nine chairs in the dining room had plastic covering that were split or torn, exposing the inside padding;* A blue couch in a common area had silver duct tape wrapped around a section of one arm;* Frayed carpet was observed in two areas where the carpet had separated from the rubber floor stripping leading to non-carpeted rooms;* The protective coating on the surface of the wooden dining room table in the common area across from the nurses station was worn/chipped, exposing bare wood;* The hallways baseboards were lose and/or lifted away from the wall surface; * Doors and door frames throughout the facility had chips, gouges and/or scrapes and black markings; * The weather stripping around residents' room doors were worn off, leaving small areas without the stripping pieces;* Multiple plastic corner guards were cracked and/or broken;* Walls throughout the facility had scrapes or gouges, including corners next to hand wash sinks; and* Four wooden benches in the hallways had scratches and scrapes, exposing bare wood surfaces.The areas in need of repair were shown to and reviewed with Staff 1 (Administrator), Staff 2 (Owner/RN) and Staff 4 (Maintenance Director) on 06/01/22. No further information was provided.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. This is a repeat citation. Findings include, but are not limited to:The facility was toured on 8/16/2022 at 10:45 am and multiple areas needing cleaning and/or repair were identified. * A plastic kick plate was added to resident room doors. Some of these doors had a metal corner guard added to the left side (hinge side) of the door in the area of the kick plate. The rooms which did not have this guard added, and which appeared to need it based on scrapes and gouges present, were: 20, 24, 26, 29, 32, 34, and doors to bathrooms A and G;* Multiple window sills throughout the facility had gouges and scrapes, exposing bare wood;* The hallway handrails had worn varnish which exposed bare wood and/or had chips or splintering wood in multiple areas;* Baseboards throughout the facility had black scuff marks, exposed bare wood on top, bottom, or side edges, and/or were separating from the wall;* Multiple wood benches, end tables, coffee tables, and chairs throughout the facility had scrapes and gouge marks, which exposed bare wood;* There were chips, scrapes, gouges, black marks, and missing paint on the walls in many locations throughout the facility;* There were multiple broken plastic corner guards throughout the building;* The caulking at the top of the back splash was missing on the hand washing sink next to Room 24;* The pipe cover under the hand washing sink between Rooms 16 and 17 was broken;* Dining room tables in several locations had worn varnish, which exposed bare wood;* There was a chip in the laminate top of a table in the dining room;* Dead bugs were visible in light fixture covers throughout the facility;* There were two cracked light covers in the kitchen;* The adhesive shelf-paper covering on a folding table in a common area was peeling off, exposing bare wood;* There were splatters, black matter, dried food, and/or chipped paint on the walls and floor in the dining room around the dirty dish hatchway;* Multiple window screens throughout the facility were fraying;* The wood table trestles in the dining room had a build-up of dark matter;* There were food splatters on the piano cover in the dining room;* Seven vinyl chairs had rips or places where the vinyl had peeled off;* There were dark stains on the carpet throughout the facility; and* The metal on bottom right corner of the left-hand door to the garbage can area was broken.Staff 1 (Administrator) was informed, and acknowledged, the environment remained out of compliance on 08/16/22 at 1:00 pm.