The findings of the change of ownership survey, conducted  08/12/24 through 08/13/24, 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 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 first re-visit to the re-licensure survey of 08/13/24, conducted on 10/21/24, 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 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

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

Observations of the kitchen on 08/12/24 and 08/13/24 showed the following areas needed cleaning or repair:

* Drips, splatters, and/or debris were observed inside cupboards, under shelves, on top of dry goods, inside drawers, and on the walls throughout the kitchen and dry storage;

* Multiple light fixtures throughout the kitchen and dry storage had dust, hanging cobwebs, black accumulation, debris, and/or dead insects on or inside the light covers;

* Black discoloration and accumulation were noted along the floor edges, cabinets, baseboards, around the edges of equipment, and at the door edges;

* Shelving in multiple refrigerators and/or freezer units had spills, debris, white/tan accumulation with dangling pieces, rust, and chipped/peeling shelf coating;

* Chipped cupboards and shelves were noted throughout the kitchen with exposed particle board;

* Chipped laminate was noted on counter edges, and the back splash was pulling away from the wall along the counter behind the small eye wash sink;

* Gaps were noted in the shelf coverings in the dry storage, which allowed spills and debris to accumulate next to the food items;

* Delivery carts, with clean items stored on them, were noted to have food debris and crumbs on the shelves next to the clean items;

* Four cutting boards were worn, with numerous deep grooves;

* Thick cobwebs, dust, and dead insects were noted in the windowsills. The blind closest to the dishwashing area had a large, thick clump of cobwebs with numerous dead insects hanging over the clean dish area; and

* Flooring throughout the kitchen had large black/gray stains, deep gouges, cracked and lifting pieces of laminate, and missing pieces of laminate.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 4 (Dietary Manager) on 08/12/24 and 08/13/24. The staff acknowledged the findings.

1.

All areas requiring cleaning will be cleaned by kitchen staff and/or the maintenance director.

Flooring and other repairs are being worked on, securing bids and financing options.

Facility has replaced the cutting boards.

2.

Education on cleaning and upkeep of the kitchen will be provided to dietary dept staff.

Dietary manager will create and maintain a cleaning/upkeep schedule for the kitchen.

3.

The Administrator and Dietary Manager will complete monthly rounds of the kitchen to ensure cleanliness and upkeep of equipment and the environment.

4.

The Administrator and Dietary Manager will be responsible to assure cleanliness and upkeep of the kitchen environment.

Based on observation and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

The areas were not reviewed during the survey. The facility received an extension to the allegation of compliance date and the areas will be reviewed after 01/15/25.

The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator/RN) on 10/21/24. She acknowledged the findings.

This POC is not required. It is my understanding that an extension of the compliance date has been granted in order to complete the work necessary. That date is extended to 1/15/2025.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code and that fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records, reviewed between 03/2024 and 08/2024, showed drill documentation was lacking in the following areas:

* The escape route used;

* Staff members on duty and participating;

* Evidence of alternate routes used;

* Evacuation time-period needed; and

* The number of occupants evacuated.

Additionally, the records reviewed did not show life safety training was provided on alternating months from the fire drills.

The need to ensure all required components were addressed and documented for each fire drill, and that drills were conducted on alternating months from life safety training, was discussed with Staff 1 (Administrator) and Staff 2 (Maintenance) 08/13/24. The staff acknowledged the findings.

1.

The Maintenance Director will conduct a fire drill to include the required documentation.

The maintenance director and administrator will conduct a life safety training to include the required documentation

2.

The maintenance director and administrator will review the life safety rules at C-420 for comprehension.

The maintenance director will create a drill / training calendar template to ensure all drills and trainings are completed per the rule.

3.

The administrator will review the template and all completed drill/training documentation monthly for compliance.

4. The administrator will be responsible to assure corrective actions are being completed as stated.  

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

Observations of the facility on 08/12/24 and 08/13/24 showed the following areas in need of cleaning or repair:

* Multiple walls, doors, and door frames in the facility had scrapes, dings, chips, missing pieces of wood, and spills:

* Chipped and scraped cupboards and counters were noted in the common area bathrooms;

* The floor in the laundry room had large pieces of flooring that were missing and/or cracked;

* The counter at the front window near the facility entrance had multiple large pieces of laminate missing, leaving some areas sharp to the touch;

* A control box for heating/cooling near the front of the dining room was hanging by its wires from the wall;

* Multiple areas of the laminate floor throughout the dining room and halls were pulling apart at the seams, bubbling, or had significant cracks and missing pieces;

* Multiple stains were noted to the carpets throughout the facility. Additionally, there were areas in the front hallway where the carpet was bubbling/puckering, creating a potential tripping hazard. Two sections of the hall carpet were pulling apart at the seam;

* Common bathrooms had black/yellow discolored and/or missing caulking around the toilets. Black/gray stains were noted to the floor near the toilets and sink areas;

* Numerous ceiling tiles in the living room and hallway were chipped and gouged with pieces missing and/or had dark stains;

* Multiple pieces of equipment, including a Hoyer lift, two geri chairs, and a commode chair, were stacked in or near the resident patio and smoking areas;

* Caulking around the sink in the bathroom was stained black; and

* Cupboards and drawers in the dining room had debris, spills, or chips, with exposed particle board and wood surfaces.

The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Administrator) on 08/12/24 and 08/13/24. The staff acknowledged the findings.

1.

Flooring and other repairs are being worked on, securing bids and financing options.

The equipment near the resident smoking area has been removed.

2.

The maintenance director and administrator will review the rule at C-513 for comprehension.

The maintenance director will create a schedule for weekly/monthly maintenace and upkeep to the environment which will include the areas of concern.

3.

The administrator and maintenance director will conduct monthly walking environmental rounding to ensure the facility environment is clean and in good repair.

4.

The administrator will be responsible to oversee corrections and on-going maintenance of the environment.

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

The areas were not reviewed during the survey. The facility received an extension to the allegation of compliance date and the areas will be reviewed after 01/15/25.

The need to ensure the interior environment was clean and in good repair was discussed with Staff 1 (Administrator/RN) on 10/21/24. She acknowledged the findings.

This POC is not required. It is my understanding that an extension of the compliance date has been granted in order to complete the work necessary. That date is  extended to1/15/2025.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to:

Observations on 08/12/24 and 08/13/24 showed four exit doors, used by residents to exit the building to the gazebo area, smoking area, and/or the front of the building, did not have an operational alarm or other acceptable system to alert staff when residents exited the building.

The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (Administrator) on 08/13/24. She acknowledged the findings.

1.

The facility will install an audible alarm on the exit doors.

2.

The maintenance director and administrator will review the rule at C-555 for comprehension.

3.

Staff will be educated on the audible door system.

The maintenance director will audit/check the audible door alarms weekly to ensure proper functionality.

4.

The administrator will review the maintenance director audits of door alarms monthly and as needed.