The findings of the re-licensure survey conducted 03/07/22 through 03/09/22 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 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 re-visit to the re-licensure survey of 03/09/2022, conducted on 05/26/2022, are documented in this report. It was determined the facility was in was in substantial 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.

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:

a. On 03/07/22 at 2:30 pm and 03/08/22 at 11:00 am, the facility kitchen was observed to need cleaning and repair in the following areas:

*Floors throughout the kitchen had black matter build-up, food debris, and grease in corners, under equipment, and around perimeter edges;

*Baseboards throughout the kitchen and dry storage area had black accumulation along the top edges;

*Interior and exterior of the three ovens had a buildup of grease and burnt food debris;

*Pipes behind multiple appliances and above cooking areas had grease, dirt, and debris on them;

*Ceiling and wall vents had an accumulation of lint and dust on the grates;

*Debris on bottoms of drawers and cabinet shelves;

*Top of dish machine, walls, pipes, gauges, and flooring behind/underneath the dish machine and sink had an accumulation of black matter, dirt, and debris;

*Windows and window screens in the dish machine area had an accumulation of dust, debris, and cobwebs;

*A storage closet that contained multiple kitchen supplies and cooking utensils needed to be cleaned and items stored appropriately; and

*The service area counter and sink outside of the kitchen had food spills, splatters, and debris on the bottoms of drawers and cabinet shelves.

b. The following areas needed repair:

*Caulking in multiple areas throughout the kitchen, including the dish machine area;

*Ceiling light covers missing in the dry food storage area, the walk-in refrigerator and freezer, and the dish machine area;

*Kitchen doors and frames had chipped paint and gouges; and

*Multiple areas had deteriorated grout and floor tiles throughout the kitchen.

c. Kitchenette area:

*Accumulation of dust and debris along the perimeter of baseboards;

*Caulking behind the sink and between the counter and wall was dark brown; and

*The cabinet under the sink had food spills and debris inside.

The areas needing cleaning and repair were discussed and toured with Staff 1 (Executive Director) on 03/09/22. He acknowledged the findings.

Deficiency C240 was noted throughout the Kitchen, Dry Storage Area, Freezer, Walk-In Cooler, Dishwasher Room, Service Area, Assisted Living Kitchenette and Dining Room.  

1.  The long-term deep cleaning of these areas will be accomplished by a contract commercial cleaning company to ensure the kitchen is regularly deep cleaned.  We have reqested proposals from two local companies and they came on-site on March 22 and 24 to review the work request.  We are still awaiting pricing and proposals from 1 of the companies.  In the near-term, this cleaning will be accomplished by Kitchen/Dining, Housekeeping, and Maintenance Department staff.  The following areas will be deep cleaned:  Floors and baseboards throughout the kitchen and Assisted Living kitchenette, ovens and deep fryers, the pipes behind and above the cooking area, the ceiling and wall vents, bottoms of drawers and cabinent shelves, the dish machine room, all windows and window screens throughout the kitchen, the storage closet and service counter area.  Deep cleaning these areas will be completed by April 30, 2022.  The Maintenance Manager is coordinating all repairs in the noted areas:  caulking throughout the kitchen and Assisted Living kitchenette, ceiling light covers, refrigerator, freezer, and dish machine area.  The grout and floor tile throughout the Kitchen will be cleaned.  These areas are expected to be done by May 1, 2022.  

2.  This deep cleaning will be monitored on a bi-weekly basis for compliance by the Executive Chef to ensure this violation will not happen again.  Additionally, Execuitive Director cleanliness reviews will be implemented in these areas on a montly basis.  Completion of these rounds will be documented in the building maintenance system (TELS).

3.  These areas will be monitored for compliance on a bi-weekly basis.

4.  The Executive Chef and Executive Director will be responsible for ensuring that these areas have been corrected and ongoing monitoring.  

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs. Findings include, but are not limited to:

During the re-licensure survey 03/07/22 through 03/09/22, there was a lack of scheduled and unscheduled activities provided for residents.

During an interview on 03/09/22, Staff 2 (Assisted Living Administrator) provided the following information:

The facility had an Activity Director assigned to the the independent living area of the facility but did not currently have an Activity Director assigned to the assisted living area and there was no current structured activity program or activity calendar in place for the assisted living residents. The facility was actively seeking to employ an Activity Director to assign to the assisted living facility and in the meantime caregiving and universal worker staff were providing some activities to residents but there was no documented evidence of those activities.

The need to ensure the facility provided a daily program of social and recreational activities that are based upon individual and group interests, physical, mental, and psychosocial needs was discussed with Staff 1 (Executive Director) and Staff 2 on 03/09//22. They acknowledged the findings.

Deficiency C242 was noted in the Assisted Living social and recreational activities program due to lacking scheduled and unscheduled activities.

1.  The Executive Director assigned a caregiver on the day shift and swing shift, by name, as the Activities Coordinators for Assisted Living.  These Activities Coordinators will be assisted by our Independent Living Actitivies Coordinator to ensure available activities are based on the Resident's individual interest and physical, mental, and psychosocial needs.  Our Health Center Administrator will oversee this work.

2.  There are several activities in Independent Living that Assisted Living Residents already participate in, but their participation has been poorly documented.  The Assisted Living Administrator and Independent Living Activities Coordinator will meeting every Monday to review the activities calendar for the week that will be beneficial for the Assisted Living Residents to participate in.  The documentation for their participation in activities will be added to the chart as a PRN note to prompt the caregivers to ensure they are transported to any activity and then more accurately document their participation.  As an example, five Assisted Living Residents attend Catholic mass every day, the PRN note will be placed in their chart as Mass Attendance, the caregiver will then be able to document that they actually did participate in the activity.  As a final step, the Executive Director will add an Activities section to the Assisted Living Weekly Status report that is submitted to a management and ownership to ensure this item remains visible to them as well.

3.  Participation in activities will be reviewed on a quarterly basis at the time of the Service Plan review.  The Assisted Living Administrator and the Assisted Living Nurse will be responsible for completing the activities review as part of the Service Plan review.

4.  The Executive Director will be responsible for monitoring the implementation and completion of these changes.  They will be an ongoing item on the Assisted Living Weekly Status Report.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated and resident specific interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution for 2 of 3 sampled residents (#s 1 and 3) who experienced changes of condition related to falls. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 2019 with a diagnosis of hypertension.

Review of Resident 3's clinical records including progress notes dated 01/01/22 through 03/06/22, incident reports, and service plans were reviewed during survey and indicated the resident experienced seven unwitnessed, non-injury falls.

a. There was no documented evidence the facility determined resident specific fall prevention interventions when Resident 3 experienced unwitnessed, non-injury falls on the following dates:

01/12/22, 01/15/22, 01/17/22, 01/31/22 and 02/01/22.

b. On 01/18/22, Resident 3 experienced two unwitnessed, non-injury falls. The facility completed a "change in service plan" document which stated the facility implemented a "pad alarm and fall mat for safety" and two hour checks as fall prevention interventions. There was no documented evidence the facility monitored the effectiveness of the interventions.

The need to ensure short-term changes of condition were evaluated and resident specific interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution was discussed with Staff 2 (Assisted Living Administrator) on 03/09/22. She acknowledged the findings.

2. Resident 1 was admitted to the facility in 05/2021 with diagnoses including mild dementia and lower extremity edema.

Resident 1's service plan noted he/she was a high risk for falls and instructed staff to assist with keeping pathways clutter free, and to report to nurse if staff observed the resident had difficulty with caring for pet cat, shortness of breath with walking, increased swelling of lower extremities that made it hard for him/her to walk, change in gait, ability to balance, change in level of consciousness, increased confusion and refusal to use adaptive equipment (wheelchair, walker) or if the resident fell.

A review of the resident's record revealed he/she experienced a non-injury fall on 01/10/22 and a fall with injury on 01/23/22.

There was no documented evidence interventions were monitored for effectiveness after each fall.

The need to monitor the effectiveness of interventions for changes of condition was discussed with Staff 2 (Assisted Living Administrator) on 03/09/22. She acknowledged the findings.

Deficiency C270 was noted in Resident #s 1 and 3 by failing to ensure short-term changes of condition were evaluated and resident specific interventions were determined, documented, communicated to staff, and monitored weekly through condition resolution, on residents who experienced changes of condition related to falls.

1.  Based on Deficiency C270, we are developing a standardized fall protocol.  This protocol will be utilized after every resident incident involving a witnessed or unwitnessed fall.  This protocol will describe in detail the process for intervening in any fall incident including the initial incident intervention, fall prevention interventions, and documentation requirements.  The new "Falls Protocol" includes having the Assisted Living Administrator and Assisted Living Nurse do a weekly follow up on the effectiveness of any new intervention to prevent the resident from having more falls.  After reviewing these interventions at the end of the week, the intervention will be determined to be effective or not.  If not effective, the Assisted Living Administrator and Assisted Living Nurse will add new interventions.  After reviewing the new interventions at the end of the next week, if it is determined by the Assisted Living Administrator or Assisted Living Nurse that these interventions are still ineffective, they will do a new evaluation on the resident and update their service plan.  All interventions are going to be added to the service plan.  The effectiveness of each intervention will be documented in the resident medical record by the Assisted Living Nurse.

2.  Establishing a standardized "Fall Protocol" will ensure that all staff respond consistently to any fall incident.  This step-by-step guide will be reviewed and acknowledged during staff training and performance reviews.  Use of the "Fall Protocol" will be a review item for the Assisted Living Administrator and Assisted Living Nurse during their quarterly service plan reviews.  This review will be specifically documented in each resident's service plan.

3.  Documentation of the "Fall Protocol" will be reviewed on a monthly basis by the Assisted Living Administrator and the Assisted Living Nurse for the first three months after implementation to ensure that we're utilizing the "Fall Protocol" effectively after every fall incident.  After three months of successful use, the evaluation will be completed on a quarterly basis along with the resident service plan review.

4.  The Assisted Living Administrator will be responsible for ensuring that the "Fall Protocol" is implemented and the monthly/quarterly reviews are completed and appropriately documented.  The Executive Director will be responsible for ensuring that corporate leadership is notified of these reviews and documentation on the Assisted Living Weekly Status Report.  

Based on observation and interview, it was determined the facility failed to ensure resident use pathway edges did not contain drop-offs. Findings include, but are not limited to:

During a tour of the facility's exterior grounds on 03/08/22, the following observations were made:

*Pathways in the back courtyard (leading toward the small pond) and near an entry/exit door had drop offs of up to four inches along the pathway edges creating a potential tripping risk to residents; and

*The concrete near the back patio had an area that was chipped and cracked with pieces of concrete lifting up.

The pathway drop-offs and patio concrete were shown to and discussed with Staff 1 (Executive Director) and Staff 2 (Assisted Living Administrator) on 03/08/22. They acknowledged the findings.

Deficiency C510 was observed in various spots on the pathway in the back courtyard (leading toward the small pond, the patio outside the Assisted Living center, and an area near the entry/exit doors.

1.  The landscaper and Executive Director surveyed the entire area of the pathway that corresponds to the Assisted Living building.  Areas where the drop-off from the edge of the pathway is greater than 4 inches will have contractor grade stone, mulch, wood chips, and/or dirt added to these areas to improve the grade difference to as close to level as possible.  The following areas will be corrected:  sidewalk on both sides of the D wing exits, the walking path leading to the pond, the patio area near the Assisted Living back exit, and the sidewalk area leading up to and around the pond.  The pond bridge will require major construction and a contract has been awarded for completion to the required specifications, this is the only outlier that may not be completed prior to May 6, 2022.  

2.  Monitoring these areas has been assigned to the Landscaper and Maintenance Manager.  Checking this item will be added to the building maintenance system (TELS) to ensure that these grades are checked on a semi-annual basis for deterioration.

3. Using the TELS building maintenance system, the Maintenance Manager will evaluate these areas on a semi-annual basis.  

4.  The Executive Director/Administrator has been tasked with ensuring these corrections are completed and ongoing monitoring.  

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

Observations of the facility on 03/08/22, showed the following areas in need of cleaning or repair:

* The doors leading to the back courtyard, windowpanes in the activity room and overhead light fixtures in the back hallway and dining room had a build up cobwebs and insect debris;

* The ceiling and wall in the corridor near the entrance to the assisted living area of the building had what appeared to be water leakage stains in the corner;

* A wall near the washing machines in the laundry room had large holes in the drywall;

* Flooring, in a clean linen storage room, had a buildup of black discoloring/stains around the front perimeter;

* An overhead vent and surrounding ceiling in the dining room had a build up dust;

* Flooring under the sink, in the shower room, was discolored with a black matter buildup on the tiles and grout and tiles appeared warped;

* Two large overhead lights in the dining room did not have working light bulbs and/or were missing the light fixture covers;

* A section of baseboard trim was missing from the wall in the hallway near the shower room; and

* Doorframes to several resident rooms had areas of chipped and gouged paint.

The areas in need of cleaning and repaired were shown to and discussed with Staff 1 (Executive Director) and Staff 2 (Assisted Living Administrator) on 03/08/22. They acknowledged the findings.

Deficiency C513 was noted in several areas in the Assisted Living Center where cleaning or repair was required to ensure all equipment necessary for the health, safety, and comfort of the Resident was kept clean and in good repair, to include the following areas:  Assisted Living back doors to the patio/courtyard, windows, and light fixtures in the dining room, ceilings and walls throughout Assited Living, the laundry room, kitchenette,and several doors and door frames were chipped or scratched.

1.  The in-house construction contranctor and Maintenance Manager have begun the correcting these noted deficiencies.  The walls, doors, and ceilings are being painted and refurbished.  The missing baseboard will be replaced  The windows, inside and out will be pressure washed and cleaned to remove debris.  Overhead lights and vents in the Dining Room will be cleaned.  The laundry room wall has been repaired and painted.  The doorframes throughout Assisted Living will be painted a uniform color to better identify it as part of Assited Living.

2.  The upkeep and maintenance of these areas will be placed into the building maintenance system (TELS) to be reviewed on a semi-annual basis.

3.  These areas will be re-evaluated on a semi-annual basis and any further work needed will be documented in TELS.

4.  The Maintenance Manager and Executive Director are responsible for ensuring the upkeep and cleanliness of the Assisted Living spaces.