Citation #1: C0295 - Infection Prevention & Control
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-054-0050(1-5) Infection Prevention & Control
(Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991
Inspection Findings:
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment for 1 of 1 sampled resident (#1) and multiple unsampled residents dependent on staff for meal service. Findings include, but are not limited to:
General observations of lunch meal service were conducted from 01/06/25 through 01/08/25. The following was identified:
* Multiple care staff were observed providing hands on assistance with eating without preforming hand hygiene between assisting different residents;
*Multiple care staff were observed to remove dirty dishes from tables and return to assist residents with eating without preforming hand hygiene or donning clean gloves;
* One direct care staff was observed handling Resident #1’s sandwich with her bare hands and without preforming hand hygiene; and
* When providing one-on-one meal assistance, multiple care staff failed to wear a protective covering over potentially contaminated clothing.
The need to maintain effective infection prevention and control protocols was discussed with Staff 1 (Administrator) on 01/08/25 at 3:40 pm. She acknowledged the findings.
Plan of Correction:
1. The Policies and protocols we have in place to ensure a safe, sanitary, and comfortable environment are according to the Infection Prevention & Control regulations and all direct care staff have all the required trainings related to Infection Prevention & Control.
2. However, to correct this deficiency, our Infection Control Specialist immediately established a meeting with all direct care staff and discussed the topics of Infection Prevention & Control of hand hygiene, meal servings and/or feeding Residents, when and how to wear appropriate PPE. All our direct care staff have verbalized and demonstrated understanding of correct Hand Hygine performance, appropriate use of PPE, and correct steps of Infection Prevention & Control when feeding Residents.
3. Our Infection Control Specialist will supervise mealtimes arbitrarily, first weekly for a month, then once a month for three months, then quarterly, to ensure proper Infection Control & Prevention steps are followed.
4. Our Infection Control Specialist is reponsible for this plan of correction.
Citation #2: C0362 - Acuity Based Staffing Tool - ABST Time
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-054-0037 (1)(b-g) Acuity Based Staffing Tool - ABST Time
(1) DEVELOP AND MAINTAIN ACUITY-BASED STAFFING
(b) Accurately capture care time and care elements that staff are providing to each resident as outlined in each individual service plan. Established care time must be resident specific, rather than a predetermined average.
(c) Develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents.
(d) Develop ABST reports and posted staffing plans that reflect distinct and segregated areas as outlined in OAR 411-054-0070(1).
(e) If applicable, determine ABST time for residents on a Specific Needs Settings Contract and residents not on a Specific Needs Setting Contract to build posted staffing plan as outlined in this rule.
(f) Develop written policies and procedures to accurately and consistently implement the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.
(g) Provide the relevant ABST information for a specific resident if requested by the Department, that specific resident, that specific resident’s legal representative, or the Long-Term Care Ombudsman.
Inspection Findings:
Based on observation, interview and record review, it was determined the facility failed to complete an acuity-based staffing tool (ABST) to accurately capture care time and care elements that staff are providing to each resident, as outlined in each individual service plan for 1 of 2 sampled residents (# 1) and multiple unsampled residents. Findings include, but are not limited to:
On 01/08/25 at 10:15 am, the facility provided a copy of the ABST for the current residents. All residents in the facility were entered in the ABST, but it was determined the ABST did not accurately capture care time minutes in the following areas:
a. The ADL minutes required for “resident-specific housekeeping or laundry services performed by care staff” was entered as “0” for all residents.
In an interview on 01/09/25 at 8:40 am, Staff 1 (Administrator) confirmed floor staff were regularly performing housekeeping and laundry tasks such as cleaning rooms, making beds, emptying trash cans, and laundering clothes.
b. Resident 1’s evaluation indicated s/he required cueing and supervision for eating.
Lunch meal observations on 01/07/25 and 01/08/25 showed s/he also required hands on assistance with eating and drinking, as needed.
Review of the ABST for Resident 1 indicated zero minutes for eating.
On 01/09/25 at 10:20 am, the need to maintain an ABST tool which accurately captured care time minutes in all required ADL areas was discussed with Staff 1. She acknowledged the findings.
Plan of Correction:
1. It is our Facilty Policy to use the ABST tool provided by the state in order to ensure that Golden Age Memory Care has the adequate numbers of direct care staff available to provide care and to safely meet all the scheduled and non-scheduled needs of our Residents.
*Due to the fact that our Facility has a cleaning company in place regularly for cleaning & housekeeping, in the ABST form, at the housekeeping section, we had marked 0 minutes.
*It is our Facility Policy to document in the state ABST tool if a Resident needs any type of assistance while eating. Sampled Resident 1, was going through multiple changes in condition, as evidenced by provided TCPs, as well as meeting scheduled for that week with Family, Hospice Team and Facility to discuss new goal of care and changes in Resident's POC, unfortunatelly, by the time we provided a copy of the ABST tool to DHS Inspector, these new chages, were not transcripted yet in minutes on the ABST tool.
2.*To correct this deficiency, we signed into our ABST tool portal and filled out the appropriate minutes at the cleaning and housekeeping section, for each Resident.
*To correct this deficiency, we verified every single Resident's "feeding" section in the ABST tool and ensured that is marked correctly, based on our current acuity.
3. We will continue to update the ABST tool quarterly, with every new Resident move-in and with every change in Resident's condition.
4. The Facility Administrator is respossible for this plan of correction.
Citation #3: C0513 - Doors, Walls, Elevators, Odors
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors
(d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure all materials and surfaces were kept in good repair. Findings include, but are not limited to:
The interior and exterior of the facility was toured on 01/06/25 at 10:30 am and the following was identified:
Interior:
* Multiple doors, door frames, wall corners, baseboards, and trim and moldings had scrapes, dings, and missing paint;
* Resident dining tables had areas of wear and exposed wood creating an uncleanable surface; and
* A pipe under the sink in a staff bathroom had a ½ inch hole and damaged drywall surrounding the pipe.
Exterior:
* Metal railings on bilateral sides of a slope leading to the resident outside courtyard were unstable.
The facility was toured with Staff 1 (Administrator) and Staff 3 (Maintenance Director) on 01/07/25 at 1:45 pm. They acknowledged the areas in need of repair.
Plan of Correction:
1. Facility has attended to this deficiency immediately.
2.*All the doors, door frames, wall corners, baseboards, and trim and moldings that have been discovered having scrapes, dings and missing paint on them, have been resolved.
*The Resident dinning tables that had the small patches/areas of exposed wood has been resolved.
*The pipe under the sink in the staffs' bathroom that had the hole in the drywall has been resolved.
*The bilateral metal railings from the slope leading to the resident outside courtyard has been resolved and is now firm and secure.
3. Our Maintenance Director will do a monthly walk through and verify walls for any dings, scrapes, any holes, missing paint as well as on doorframes, baseboards corners, etc, and will check the dining room tables to ensure coating in place that will ensure appropriate cleaning and disinfecting of the tables surfaces, and will take action to repair immediatelly if any damages observed. Our Maintenance Director will also verify the durability/stability of our bilateral railing of the slope leading outside our courtyard.
4. Our maintenance director is responsible for this plan of correction.
Citation #4: C0530 - Housekeeping and Laundry
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-054-0200 (7)(b-d) Housekeeping and Laundry
(b) HOUSEKEEPING AND SANITATION.(A) A RCF must have a secured janitor closet for storing supplies and equipment, with a floor or service sink.(B) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(c) LAUNDRY FACILITIES. Laundry facilities may be located to allow for both resident and staff use, when a time schedule for resident-use is provided and equipment is of residential type. When the primary laundry is not in the building or suitable for resident-use, a RCF must provide separate resident-use laundry facilities. A CF is not required to provide resident-use laundry services.(A) Laundry facilities must be operable and at no additional cost to the resident.(B) Laundry facilities must have space and equipment to handle laundry-processing needs. Laundry facilities must be separate from food preparation and other resident-use areas.(C) On-site laundry facilities, used by staff for facility and resident laundry, must have capacity for locked storage of chemicals and equipment.(D) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.(d) SOILED LINEN PROCESSING. For the purpose of this rule, "soiled linens and soiled clothing," means linens or clothing contaminated by an individual's bodily fluids (for example, urine, feces, or blood).(A) There must be a separate area with closed containers that ensure the separate storage and handling of soiled linens and soiled clothing. There must be space and equipment to handle soiled linen and soiled clothing processing needs that is separate from regular linens and clothing.(B) Arrangement must provide a one-way flow of soiled linens and soiled clothing from the soiled area to the clean area and preclude potential for contamination of clean linens and clothing.(C) The soiled linen room or area, must include a flushing rim clinical sink with a handheld rinsing device and a hand wash sink or lavatory.(D) When washing soiled linens and soiled clothing, washers must have a minimum rinse temperature of 140 degrees Fahrenheit unless a chemical disinfectant is used.(E) Personnel handling soiled laundry must be provided with waterproof gloves.(F) Covered or enclosed clean linen storage must be provided and may be on shelves or carts. Clean linens may be stored in closets outside the laundry area.(G) The wall base shall be continuous and coved with the floor, tightly sealed to the wall, and constructed without voids that can harbor insects or moisture.
Inspection Findings:
Based on observation and interview, it was determined the facility failed to ensure a one-way flow of soiled laundry from the soiled area to the clean area and preclude potential for contamination of clean laundry. Findings include, but are not limited to:
Observations of the facility laundry room from 01/06/25 through 01/08/25 revealed the following:
* A basket of soiled laundry was observed on three occasions on the floor next to the countertop containing clean resident clothing;
* Uncovered pillows were stored on top of the storage cabinet and in a basket on the countertop; and
* The laundry room area housing the flushing rim sink and hand wash sink was used for storage and the sinks were not accessible to staff for soiled laundry. The area was blocked by a large storage rack from the rest of the laundry room preventing a one-way flow of soiled laundry.
The need to ensure a one-way flow of soiled laundry to preclude potential contamination was discussed with Staff 1 (Administrator) on 01/08/25 at 11:00 am. She acknowledged the findings.
Plan of Correction:
1. The Policies and protocols we have in place to ensure a safe, sanitary and comfortable environment are according to the Infection Prevention and Control regulations and all direct care staff have all the required trainings.
2. However, a meeting was established by our Infection Control Specialist and our direct care staff and the topics related to Clean versus Dirty laundry were discussed, as well as the room area housing the flushing rim sink and hand wash sink have been discussed with all direct care staff. All direct care staff have verbalized and demonstrated understanding of correct steps to fallow when performing laundry, including when handling soiled linnens.
*All the extra pillows and blankets that were stored on our laundry open shelve have been placed in covered containers.
*The additional storage shelve unit has been moved immediatelly, on 1/09/25, providing Staff will clear access to perform a one-way flow of soiled laundry.
3. Our Infection Control Specialist will verify quarterly, arbitrarily and ensure that all the correct steps of Inspection Prevention & Control are being followed when laundry is performed.
4. The Infection Control Specialist is responsible for this Plan of Correction.
Citation #5: Z0142 - Administration Compliance
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-057-0140(2) Administration Compliance
(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.
Inspection Findings:
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 295, C 362, C 513 and C 530.
Plan of Correction:
This Residential Memory Care Facility took note of all listed deficiencies in the Statement of Deficiencies and a Plan of Corrections was estabished which will be fully implemented no later than 3/10/2025.
Citation #6: Z0163 - Nutrition and Hydration
Visit History:
t Visit: 1/9/2025 | Not Corrected
Regulation:
OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration
(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.
Inspection Findings:
Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed and included in the service plan for 1 of 2 sampled residents (#1) who resided in the MCC. Findings include, but are not limited to:
Resident 1 moved into the MCC in 11/2024 with diagnoses including Alzheimer’s disease and aphasia. Resident 1 was receiving hospice services and was at risk for weight loss.
Resident 1’s service plan dated 12/05/24 was reviewed during the survey and lacked an individualized nutrition and hydration plan.
The lack of individualized nutrition and hydration plan was discussed with Staff 1 (Administrator) on 01/09/25 at 9:41 am. She acknowledged the findings.
Plan of Correction:
1. Our Policies and protocols we have in place to ensure that the Move-In Evaluation as well as the Service Plans for each Resident addressess all the required elements related to individualized nutrition and hydration, are in accordance with the Regulations and do not need updating at this time.
2. However, we have re-educated ourselves on the importance of including more individualized and person-centered nutrition and hydration preferences in the specified section. Facility RN is already completing a Diatery Assessment for every Resident that moves in our Facility, where she includes information gathered from Resident's medical history, family and Resident. In addition to this Assessment completed by our Facility RN, we have built an additional form for each Resident that will contain any diet orders or restrictions the Resident may have, as well as their perefernces, likes and dislikes related to nutrition and hydration. This form will be accessible to the Kitchen Operator as well as to all direct care staff.
3. Facility Administrator will review each Resident's Evaluation, Service Plan and Nutrition & Hydration Preferences Form quarterly and as needed with any changes.
Facility RN will review each Resident's Dietary Assessment quarterly and as needed with any changes.
4.Facility Administrator is responsible for this Plan of Correction.