Fox Hollow Independent and Assisted Living Community

The findings of the kitchen inspection, conducted 01/25/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 01/25/24, conducted 04/10/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure food was handled, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service with Staff 2 (Dining Room Supervisor) on 01/24/25 revealed splatters, spills, drips, and debris noted on: - Stand mixer; - Reach in refrigerators; - Ice cream freezer; - Exterior sides and knobs of the gas range and oven; - Walls throughout the kitchen; - Flooring and cove base throughout the kitchen; - Fans of walk-in refrigerator and freezer; - Dry storage area flooring beneath shelving; - Stainless steel and metal rack shelving surfaces, legs, and feet; - Can opener blade and casing; - Interior of cupboards and drawers in kitchen and dining room beverage station; - Bakery racks; - Underneath shelving and equipment throughout kitchen; - Dishwashing area including flooring, drains, walls, sinks, caulking, exhaust vent, and equipment; - The clean side of the dish washing area had visible debris; - Garbage can lids and sides; and - Hand washing areas including walls and equipment.* A package of raw hamburger was stored above other foods.* Boxes of food were stored on the floor in the walk in refrigerator and freezer.* Multiple dented cans were found in the dry storage.* Scoops were left in containers of food;* Packages of food were left open in the dry storage. * There were undated, uncovered, and unlabeled opened packaged and prepared foods in all refrigerators.* Expired foods were identified in the refrigerators. * The wire racks of the reach in refrigerator were chipped and corroded. * Tray line cutting boards were stained and deeply scored.* The coffee station cupboards and drawers were damaged creating un-cleanable surfaces.* Testing strips were not available to ensure the sanitizing solution was at the correct ratio. Sanitizer towels were not submerged in the sanitizing solution.* There was no evidence of monitoring of temperatures of refrigerators, the ware wash machine, or foods.* A broom and dustpan were stored leaning on a wire rack of clean dishes.* Dish racks were stored directly on the floor.* Dietary staff were observed without beard restraints. * Staff preparing food were observed to not change gloves between tasks.* A staff preparing plates and serving residents was observed with long painted nails not using gloves. The areas in need of cleaning and repair, and the food handling and storage findings were reviewed with Staff 1 (Executive Director) on 01/25/24. She acknowledged the findings.

The findings of the re-licensure survey, conducted 09/28/22 through 09/29/22 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 Home and Community Based Services Regulations OARs 411 Division 004.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 revisit to the re-licensure survey of 09/29/22, conducted 01/04/23 through 01/05/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Home, and Community Based Services Regulations OARs 411 Division 004.

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 in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observation of the kitchen on 09/28/22 revealed the following:* Food crumbs, dust, and debris on the surface of the dishwasher;* Multiple food items in the refrigerator were not covered;* Multiple food items in the refrigerator were not labeled or dated;* The shelf below the food prep area, that held clean dishes, had food and debris on it;* Multiple severely dented cans;* Cook not utilizing proper hand hygiene when handling food; and* A carton of vegetables was stored on the ground.The need to ensure the facility prepared food in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed with Staff 1 (ED) on 09/28/22. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 2 of 5 sampled residents (#s 2 and 3). Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 09/2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the care plan dated 09/09/22, showed the care plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Agitation and distressed behaviors;* Air overlay use;* Gait belt use and transfer pole;* Toileting assistance;* Weight monitoring; and* Ambulation and wheelchair propelling.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.
2. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety and urinary incontinence.The resident's 09/21/22 service plan, Kardex (the document caregivers used), MAR dated 09/01/22 through 09/28/22 and progress notes dated 06/01/22 through 09/28/22 were reviewed. The resident was interviewed on 09/28/22 at 2:15 pm and Staff 16 (Agency CG) was interviewed on 09/29/22 at 10:50 am. The service plan was not reflective and lacked clear caregiving instruction in the following areas: * Self management of liter flow use while using an oxygen concentrator; * Assistance needed for portable oxygen use and which liter the oxygen should be set at; * Self administration of an inhaler and multiple over the counter medications; * Behavior intervention of sitting and talking with the resident; * Preferred sleeping and waking times being variable; * Incontinent assistance; * Bed mobility assistance; * Once weekly escorts to the Beauty Shop; * Safety checks; and* Signs and symptoms of when the resident may be getting a urinary tract infection. The need to ensure resident service plans were reflective of current care needs and provided clear caregiving instruction was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 03/2022 with diagnoses including congestive heart failure and restless leg syndrome. Observations of the resident, interviews with staff, review of the service plan dated 08/19/22 and progress notes dated 06/01/22 through 09/28/22 were reviewed. 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:* Medication changes;* Emergency room;* Loose stools and vomiting; and* Fall and pelvic fracture. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 09/2018 with diagnoses including Multiple Sclerosis and osteoarthritis. Observations of the resident, interviews with staff, review of the service plan dated 09/09/22 and progress notes dated 06/10/22 through 09/28/22 were reviewed. 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:* Medication changes;* Behaviors and agitation;* Skin breakdown;* Eye infection and antibiotic use; and* Falls.The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to document monitoring of short term changes of condition until resolution and failed to document monitoring of residents consistent with their evaluated needs for 4 of 4 sampled residents (#s 1, 2, 3 and 4) who experienced short term changes of condition. Findings include but are not limited to:1. Resident 4 was admitted in 08/2022 with diagnoses including dementia and was evaluated as a fall risk and dependent for care needs.a. Resident 4's service plan included interventions to reduce falls. Resident 4's clinical record revealed s/he fell nine times between 08/07/22 and 09/20/22.There was no documented evidence all service planned fall interventions were monitored and reviewed to determine effectiveness with each incident. b. Resident 4's clinical record revealed:* 08/07/22 - black eye and cut to nose from a fall;* 09/2/22 - abrasions to right shoulder and knee from a fall;* 09/03/22 - abrasions to both shoulders from a fall; and* 09/20/22 - abrasion to left shoulder from a fall.There was no documented evidence the injuries had been monitored at least weekly until resolved. The need to monitor residents per their evaluated needs and to monitor changes in condition to resolution was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/RN) on 09/29/22. They acknowledged the findings.
4. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety and chronic obstructive pulmonary disease. The resident's records were reviewed and revealed the following: On 07/19/22, the facility faxed Resident 3's physician stating the resident "overused" an "inhaler", which the resident was administering independently, and requested permission for the facility to administer it from that date forward. The physician signed and returned the fax on 08/03/22, providing permission for the facility to take over the administration of the inhaler. There was no documented evidence the "overuse" of the inhaler was monitored through resolution or the facility determined and documented what interventions were needed for the resident. On 09/21/22 the physician signed an order for the resident to "trial" the inhaler again. There was no documented evidence of what the staff should be monitoring for, how long the resident needed to be monitored or interventions implemented and monitored for the "trial" use of self administering the inhaler. The need to ensure short term changes of condition were monitored at least weekly through resolution, the facility determined and documented what interventions were needed for the resident, and the interventions were monitored for effectiveness was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/28/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth.The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/28/22. They acknowledged the findings.

2. Resident 1 was admitted to the facility in 09/2018 with diagnoses including Multiple Sclerosis. The resident's 06/10/22 through 09/28/22 progress notes, 08/02/22 physician orders and the 09/01/22 through 09/28/22 MAR/TAR was reviewed.a. The MAR reflected administration instructions for the following medications:* Cholecalciferol 1000u, one tab daily;* Milk of Magnesia 30ml prn for constipation if no bowel movement in 3 days;* Mylanta 200-200-20 mg/5ml, give 30 ml by mouth every 4 hours prn for gastrointestinal upset;* Risamine Ointment 0.44-20.625% apply prn for redness/skin breakdown;* Senna tablet 8.6 mg, take one tablet prn for bowel management;* Tylenol ES tablet 500 mg, give one tablet by mouth every 6 hours prn for pain or fever; and* Glycerin Adult Suppository, give 1 suppository prn if MOM not affective if no bowel movement for 3 days.There were no signed physician orders onsite at the facility for the listed medications and treatments.b. There was a signed physician's order for staff to check the resident's oxygen saturation levels every shift and titrate oxygen use between 2-8 liters to keep oxygen saturation levels greater than 90%.The order was not reflected on the MAR and staff were not monitoring oxygen saturation levels.In an interview on 09/29/22, Staff 2 (Wellness Director/RN) indicated a fax was sent to the physician for clarification and signature regarding the medications and treatments with no signed orders. The need to ensure the facility had orders for all medications and treatments administered was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed, and signed physician orders were documented in the resident's record for all medications and treatments the facility was responsible to administer, for 2 of 4 sampled residents (#s 1 and 3) whose orders were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 01/2017 with diagnoses including anxiety.The resident's 09/01/22 through 09/28/22 MAR, physician's orders and progress notes dated 06/01/22 through 09/28/22 were reviewed. There were four entries on the MAR dated 09/06/22 through 09/09/22 stating, "Other / See Nurse Notes" relating to the administration of venlafaxine (for anxiety). There was no documented evidence of corresponding nurse notes for those days. On 09/28/22 at approximately 3:00 pm, Staff 2 (Wellness Director/RN) stated the facility was waiting for the medication delivery and confirmed the resident had not received the medication during those four days.The need to ensure the facility carried out physician's orders as prescribed was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused to consent to orders for 1 of 2 sampled residents (#3) who had documented medication and treatment refusals. Findings include, but are not limited to:Resident 3 was admitted to the facility in 01/2017 with diagnoses including chronic obstructive pulmonary disease (COPD).The resident's 09/01/22 through 09/28/22 MAR, physician's orders and progress notes dated 06/01/22 through 09/28/22 were reviewed. There was documentation of the following refusals: * Inhaler (for COPD) was documented as refused in the progress note on 08/05/22; * Polyethylene glycol powder (for constipation) on 09/07/22, 09/08/22 two times, 09/09/22, 09/24/22 two times and 09/28/22; and * Pulmicort flexhaler (for COPD) on 09/01/22, 09/02/22, 09/04/22 through 09/07/22, 09/08/22 two times, 09/09/22 two times, 09/16/22 and 09/20/22. On 09/28/22 at 3:42 pm, Staff 2 (Wellness Director/RN) confirmed there was no documented evidence the facility notified the prescriber of the refusals.The need to ensure the physician/prescriber was notified when a resident refused to consent to orders was discussed with Staff 1 (ED), Staff 2 and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate a resident's ability to safely self-administer specific medications for 1 of 3 sampled residents (#3) who were reviewed for self-administering medications. Findings include, but are not limited to:Resident 3 was admitted to the facility in 01/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and history of urinary tract infections. The resident's electronic chart was reviewed, which included all evaluations, progress notes and physician's orders.a. In a fax to Resident 3's physician on 07/19/22, it was reported the resident had "overused" an inhaler that s/he self administered. On 08/03/22 the physician faxed the facility directing staff to administer the inhaler. On 09/21/22 the resident's physician signed an order for the resident to start a "trial" of self administering an inhaler.There was no documented evidence the resident had been evaluated to assure the ability to safely self-administer the inhaler prior to 07/19/22 or on 09/21/22.b. On 09/09/22, Resident 3 returned to the facility from urgent care with the diagnosis of a urinary tract infection. Urgent care sent Cipro (an antibiotic to treat the infection) with the resident for him/her to self administer. There was no documented evidence the resident had been evaluated to assure the ability to safely self-administer the antibiotic on 09/09/22. c. During an interview with Resident 3 on 09/28/22 at 2:15 pm, there were multiple over the counter (OTC) medications observed. Due to the resident not being evaluated to assure the ability to self-administer prescribed medications, it was unknown if self-administering OTCs was contraindicated. The need to ensure residents were evaluated to assure ability to safely self-administer medications was discussed with Staff 1 (ED), Staff 2 (Wellness Director/RN) and Staff 14 (Regional RN) on 09/29/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure all pre-service training was completed prior to beginning job duties for 2 of 2 newly hired direct care staff (#s 11 and 12) and infectious disease training for 1 of 2 long term staff (#4) whose training records were reviewed. Findings include, but are not limited to:The facility's training records were reviewed on 09/28/22. Staff 11 (CG), hired on 08/30/22, and Staff 12 (MT), hired on 08/31/22, lacked documented evidence that the pre-service orientation, infectious disease training and pre-service dementia training were completed prior to beginning their job duties. Staff 4 (Community Relations Director) had no documented evidence of completing infectious disease prevention training.The need to ensure staff completed all components of the pre-service training was discussed with Staff 1 (ED) on 09/28/22. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 newly hired staff (#s 9 and 10) had documented demonstration of competency in all required areas within 30 days of hire. Findings include, but are not limited to:Review of the facility's training records on 09/28/22 indicated the following:Staff 9 (MT), on hired 06/17/22, and Staff 10 (MT), hired on 08/24/22, lacked documented evidence that competencies were demonstrated within the first 30 days of hire in the following areas: * The role of service plans in providing individualized resident care;* Providing assistance with the activities of daily living;* Changes associated with normal aging;* Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition;* Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; and* Medication pass and treatments administered.On 09/28/22, the facility ensured demonstrated competencies were documented for current staff on shift and would be documented for all additional MTs prior to performing any additional medication passes. The need to document demonstrated competency in job duties within 30-days of hire was discussed with Staff 1 (ED) and Staff 2 (Wellness Director/RN). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long term staff (#s 8 and 12) completed the minimum required 12 hours of annual in-service training, including six hours of dementia training. Findings include, but are not limited to:Facility training records were reviewed on 09/28/22 and revealed the following:Staff 6 (MT), hired on 10/11/10, and Staff 8 (MT), hired on 05/17/16, did not have documented evidence for the completion of the required 12 hours of annual in-service training, including six hours of dementia training. The need to ensure all required in-service training hours and requirements were completed annually was reviewed with Staff 1 (ED) and Staff 2 (Wellness Director/RN) on 09/28/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented every other month and fire and life safety instruction to staff was provided on alternate months. Findings include, but are not limited to:Fire drill records and fire and life safety training records from 04/01/22 through 09/28/22 were reviewed. The following deficiencies were identified:a. The facility's fire drill form lacked the following documentation:* Problems encountered and comments relating to residents who resisted or failed to participate in the drills; and* Number of occupants evacuated. b. There was no documented evidence the facility was providing fire and life safety instruction to staff on alternating months.The requirements regarding fire drills and fire and life safety instruction for staff was reviewed with Staff 1 (ED) on 09/28/22. Staff 1 acknowledged the facility was not relocating or evacuating residents during fire drills and the facility was not providing fire and life safety instruction to staff .

Based on interview and record review, it was determined the facility failed to ensure fire and life safety instruction was provided to residents upon move in and at least annually. Findings include, but are not limited to: Fire drill records and fire and life safety training records from 04/01/22 through 09/28/22 were reviewed on 09/28/22. The records lacked documented evidence that residents had received training within 24 hours of admission and were re-instructed annually in the following areas: * General safety procedures;* Evacuation methods;* Responsibilities during fire drills; and* Designated meeting places inside or outside the building.A written record of fire safety training, including content of the training sessions and the residents attending was not maintained by the facility. The need to ensure residents received fire and life safety training on admission and were re-instructed annually was discussed with Staff 1 (ED) on 09/28/22. She acknowledged the findings.