Inspection Report
Renewal
Capacity: 75
Deficiencies: 15
Jan 25, 2024
Visit Reason
State-compiled facility profile showing 2 inspections from 2022-2024 with deficiency history and compliance findings.
Findings
The facility had one recent inspection in January 2024 with no deficiencies and a prior re-licensure survey in September 2022 with multiple deficiencies primarily related to resident services, infection control, staffing training, fire and life safety, and building maintenance. Many deficiencies were corrected by January 2023, but some remained uncorrected.
Deficiencies (15)
| Description |
|---|
| C0000 - Comment: The findings of the kitchen inspection, conducted 01/25/24, 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. |
| C0000 - Comment: The findings of the re-licensure survey, conducted 09/26/22 through 09/27/22, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, and OARs 411 Division 004 Home and Community Based Services Regulations. |
| C0240 - Resident Services Meals, Food Sanitation Rule: Failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Observed splatters, spills, drips, debris on shelves, floors, dishwashing area, and equipment; dishwashing racks stored on floor. Reviewed with ED and Dietary Services Manager. |
| C0252 - Resident Move-In and Eval: Res Evaluation: Failed to ensure evaluations were performed within the first 30 days of move in for 1 of 1 sampled resident. No documented evidence of review within 30 days. Acknowledged by RCC and ED. |
| C0260 - Service Plan: General: Failed to ensure service plans were updated within 30 days of admission reflective of residents' needs and provided clear caregiving instructions for 3 of 5 sampled residents. Issues included inaccurate assistance needs and incomplete caregiving instructions. Acknowledged by ED, RN, and Health Services Director. |
| C0270 - Change of Condition and Monitoring: Failed to ensure residents with short term changes of condition were evaluated, monitored weekly to resolution, and interventions re-evaluated for effectiveness for 4 of 5 sampled residents. Issues included lack of documentation for monitoring infections, injuries, falls, depression, and other conditions. Acknowledged by ED, Corporate RN, Health Services Director, and RCC. |
| C0295 - Infection Prevention & Control: Failed to ensure staff consistently wore face masks properly as required by OAR 333-019-1011. Multiple instances of improper mask use observed. Acknowledged by ED, RN, and Health Services Director. |
| C0370 - Staffing Requirements and Training – Pre-Serv: Failed to ensure all pre-service orientation and dementia training was completed prior to job responsibilities for 3 newly hired staff. Missing infectious disease prevention, fire safety, and dementia training. Acknowledged by ED. |
| C0372 - Training Within 30 Days: Direct Care Staff: Failed to ensure 1 of 3 newly hired staff had documented competency demonstration and 2 of 3 had First Aid and abdominal thrust training within 30 days of hire. Acknowledged by ED. |
| C0374 - Annual and Biennial Inservice For All Staff: Failed to have documented evidence of 12 hours annual in-service training including 6 hours dementia care for 2 long-term staff. Acknowledged by ED. |
| C0420 - Fire and Life Safety: Safety: Failed to ensure fire and life safety training and drills were conducted on alternating months with all required components documented. Inconsistent documentation of drills and training. Acknowledged by ED. |
| C0422 - Fire and Life Safety: Training For Residents: Failed to ensure residents received annual training on general safety, evacuation, fire drill responsibilities, and meeting places. Acknowledged by ED. |
| C0610 - General Building Exterior: Failed to maintain exterior pathways in good repair. Sidewalk drop-offs up to three inches presented tripping/fall risks. Acknowledged by ED. |
| C0613 - General Building: Doors-Walls, Cleanable: Failed to ensure interior environment was clean and in good repair. Issues included stained carpets, damaged drywall, broken toilet, dirty windows, and broken exterior light. Acknowledged by ED. |
| C0640 - Heating and Ventilation: Failed to ensure wall heater covers did not exceed 120 degrees F. Fireplace frame measured 247.6 degrees F. Acknowledged by ED. |
Report Facts
Inspections on page: 2
Total deficiencies: 13
Licensed beds: 75
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff 1 | Executive Director (ED) | Named in multiple deficiency findings and acknowledgements |
| Staff 2 | Registered Nurse (RN) / Corporate RN | Named in infection control and change of condition findings |
| Staff 3 | Health Services Director | Named in multiple deficiency findings and acknowledgements |
| Staff 4 | Resident Care Coordinator (RCC) | Named in resident evaluation and change of condition findings |
| Staff 5 | Dietary Services Manager | Named in food sanitation deficiency |
| Staff 7 | Medication Technician (MT) | Named in annual inservice training deficiency |
| Staff 8 | Medication Technician (MT) | Named in pre-service and training deficiencies |
| Staff 9 | Caregiver (CG) | Named in pre-service and training deficiencies |
| Staff 11 | Caregiver (CG) | Named in annual inservice training and service plan deficiency |
| Staff 12 | Caregiver (CG) | Named in pre-service orientation deficiency |
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