The findings of the change of ownership survey, conducted 03/07/23 through 03/09/23, 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 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.

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

MCC:Memory 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 03/09/23, conducted 08/01/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to:

The facility was endorsed as a secure Memory Care Community for residents with a diagnosis of dementia. The building consisted of eight individual units, called "cottages," where residents resided. Each cottage included a kitchenette.

During a tour of the eight cottages on 03/07/23 between 9:20 am and 11:25 am, and during other observations during the survey, the following issues were observed:

* Gated doors which kept residents from wandering into the kitchenettes were left unlatched in Cottages 2, 4 and 7.

* Cabinets underneath the sinks in the kitchenettes where chemicals were stored were left unlocked in Cottages 1, 7 and 8.

* Cabinets in the kitchenettes where bread knives and carving knives were stored were left unlocked in Cottages 4 and 8.

Access to the unsecured areas represented a threat to the safety and welfare of residents.

The need to ensure staff exercised reasonable precautions to maintain a secure environment for residents was discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 03/08/23. They acknowledged the findings.

The Cottages Senior Living will exercise reasonable precautions against any condition that could threaten the health, safety or well-being of residents.

Gated kitchenette doors in cottages will be kept locked at all times when not in use.

Cabinets under cottage kitchenette sinks will be kept locked at all times when not in use.  

Cabinets /drawers in cottage kitchenettes where bread knives and carving knives are stored will be kept locked at all times when not in use.

At time of survey, the above mentioned deficiencies were locked and secured.

Bi-weekly audits will be completed by Food & Beverage Director or Designee to assure compliance.  

Audits will be reviewed during Monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance.

All staff meeting was held on March 10, 2023 and on April 10, 2023; training topic will include exercising reasonable percautions that could threaten the health, safety or well-being of residents.  

Executive Director (ED) and Food & Beverage Director will be responsible.   

2.  Resident 6 was admitted to the facility in 04/2020 with diagnoses including late onset Alzheimer's disease and Barrett's esophagus.

The resident's 02/21/23 outside provider significant change care plan, 10/13/22 service plan and service plan updates (SPU's) were reviewed during the survey. The significant change care plan revealed the following information:

* Recent choking episode, severe dysphagia and general decline in function;

* Food texture: puree;

* Aspiration precautions: position, sitting upright 90 degrees for all eating/drinking;

* Swallow strategies: small bites, no straws, if participant begins to cough, choke, sneeze, have wet voice or runny nose/eyes while eating, cue to stop eating, resume only after cleared, wait 30 minutes after meals before laying down; and

* Oral care: two to three times daily.

In a 03/08/23 interview with Staff 9 (Personal Care Lead), she stated she had not received instruction on aspirations interventions for Resident 6.

There was no documented evidence Resident 6's service plan provided clear direction to staff related to food texture and aspiration precautions.

The need to ensure service plans included clear direction to staff was discussed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents' service plans were reflective of residents' needs and provided clear directions regarding the delivery of services for 2 of 8 sampled residents (#s 6 and 7) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 7 was admitted to the facility in 02/2023 with diagnoses including major neurocognitive disorder due to Alzheimer's disease.

Observation of the resident's ADL care on 03/09/23, interviews with staff, and review of the current service plan, dated 02/16/23, revealed Resident 7's service plan was not reflective of the resident's current status in the following areas:

* Dressing/undressing;

* Bathing;

* Toileting; and

* Transfer.

The need to ensure the service plan reflected residents' current needs was reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23 at 12:15 pm. They acknowledged the findings.

The Cottages Senior Living will ensure all resident service plans are reflective of residents' needs and provide clear directions to team members regarding the delivery of services.

Service plans will be updated and will be updated as needed to include resident changes. These updates will be written to provide clear direction to team members regarding the delivery of services.   

A "Service Plan Update" form will be used to update a service as needed.  Clear instructions will be written on form to provide clear direction to team members regarding the delivery of service.

The two resident service plans noted in deficiency were updated to reflect current needs and clear directions to team members regarding delivery of services.

Weekly audits will be completed by ED and RSD to assure complaince.

Audits will be reviewed at Monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance.  

A license nurses meeting will be held on March 23, 2023; training topics to include service plans, updates to service plans, resident changes and clear direction to team members regarding the delivery of service.

All staff meeting will be held on April 10, 2023; training topics to include service plans, resident changes and clear directions to team members regarding the deliver of service.  

ED and Resident Services Director (RSD) will be responsible.  

Based on observation and interview, it was determined the facility failed to maintain all exterior pathways and accesses to the RCF common-use areas in good repair. Findings include, but are not limited to:

The building consisted of eight individual units, called "cottages," where residents resided. Each cottage had access to an outdoor recreation area.

During a tour of the outdoor areas on 03/07/23, the patio of Cottage 7 and sections of pathways of Cottages 7 and 8 were noted to have drop-offs of up to three inches, measured from the concrete to the planting bed surface. These areas represented potential tripping hazards for residents.

The drop-offs were discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 03/08/23. They acknowledged the drop-offs were a risk to the residents.

The Cottages Senior Living will maintain all exterior pathways and accesses to community's common-use areas in good repair.

The two cottage outdoor areas noted in deficiency will be fixed, maintained and in good repair to remove tripping hazards.  

Bi-monthly walk through audits of cottage outdoor areas will be completed by Maintenance Director to assure no tripping hazards.  

Audits will be reviewed during Monthly Quarterly Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance.

All staff meeting will be held on April 10, 2023; training topic to include cottage outdoor areas in good repair.  

ED and Maintenance Director will be responsible.  

Based on observation and interview, it was determined the facility failed to maintain all interior materials and surfaces clean and in good repair. Findings include, but are not limited to:

The building consisted of eight individual units, called "cottages," where residents resided. Each cottage included a kitchenette.

During a tour of the eight cottages on 03/07/23, between 9:20 am and 11:25 am, the following issues were observed:

* Cottage 1: A section of baseboard in the hallway outside the kitchenette was damaged and paint was deteriorated;

* Cottage 5: The bathroom door frame of resident room 502 had bare wood where the door had been removed, creating an uncleanable surface;

* Cottage 7: The interior and handle of the microwave had grease and debris buildup and the interior of the freezer contained some debris;

* Cottage 8: There were multiple holes or other minor damage on the walls in the hallways, paint was worn off areas of the handrails, there was debris in the interiors of the freezer and refrigerator and the freezer handle was broken;

* Multiple drawer pulls and handles were missing from the kitchenette cabinets in Cottages 5, 6, 7 and 8; and

* Several upper cabinet shelves in each of the kitchenettes had areas where the finish was worn down to the bare wood, creating an uncleanable surface.

The areas needing cleaning or repair were reviewed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 03/08/23. They acknowledged the findings.

The Cottages Senior Living will assure all internal materials and surfaces are kept clean and in good repair.

Maintenance Director or Designee will fix all repairs noted in deficiency.

Maintenance Director or Designee wil clean all areas noted in deficiency.   

Bi-monthly walk through audits will be completed by ED and Maintenance Director in cottages to assure internal materials and services are clean and in good repair.  Items found not to be clean and in good repair during audits will be addressed accordingly.  

Audits will be reviewed during Monthly Quality Assurance/Quality Measurement meetings to assure compliance and evaluate internal system to keep in compliance.  

All staff meeting will be held April 10, 2023; training topic internal material surfaces need to be kept clean and in good repair.

ED and Maintenance Director will be responsible.  

Based on observation and interview, 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 160, C 510 and C 513.

The Cottages Senior Living will be in compliance with both the Memory Care Communities Administrative Rules and Residential Care Facilities Administrative Rules. See Plan of Correction for Tags C160, C510 and C513.

ED or Designess will be responsible.  

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C 260.

The Cottages Senior Living will be in compliance with both the Memory Care Communities Administrative Rules and Residential Care Facilities Rules.  See Plan of Correction for C260.

ED or Designee will be responsible.    

Based on interview and record review, it was determined the facility failed to ensure an individualized nutritional plan for each resident was developed and included in residents' service plans for 1 of 6 sampled residents (# 4). Findings include, but are not limited to:

Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia.  

The resident's medical record and current service plan was reviewed during the survey. The record reflected choking episodes due to poor dentation. The service plan reflected the resident would drink seltzer water, "loved" sweets and chicken fettuccini and was a picky eater.

In an interview with the resident's family member on 03/07/23 at 2:05 pm, s/he stated the family brought snacks including pudding, applesauce, yogurt, frozen chicken fettuccini entrees and electrolyte drinks to the facility each week for the resident.

In an interview with Staff 6 (Personal Care Lead) on 03/08/23 at 10:47 am, she verified the family brought in snacks, the resident only drank apple juice and the electrolyte drinks and consumed 50% or less of each meal. Staff 6 also stated Resident 4 was on a mechanical soft diet.

There was no documented evidence the above information was included in the resident's service plan.

The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23. They acknowledged the findings and agreed more individualized nutrition and hydration information was needed on the resident's service plan.

The Cottages Senior Living will ensure all residents' individualized nutrition plan is developed and is included on resident service plans.

The one resident nutrition plan noted in deficiency was  updated to reflect resident's current nutrition and hydration needs.

Audits will be reviewed during Monthly Quality Assurance/Quality Measurement meetings to ensure compliance and evaluate internal system to keep in compliance.  

Weekly audits will be completed by ED and RSD to ensure compliance.  

Licensed nurses meeting will be held on March 23, 2023; training topic to include residents' individualized nutrition plans.

All staff meeting will be held on April 10, 2023; training topic to include residents' individualized nutrition plans.

ED and RSD responsible.

Based on observation, interview and record review, it was determined the facility failed to develop an individualized activity plan based on the resident's activity evaluation, for 3 of 7 sampled residents (#s 2, 4 and 6) whose activity plans were reviewed. Findings include, but are not limited to:

Residents 2, 4 and 6 resided in different cottages of the Memory Care Community and were diagnosed with dementia. Each resident was observed needing various degrees of assistance to initiate and participate in activities.

1. Resident 2 was admitted to the facility in 05/2021 with diagnoses including dementia.

Though Resident 2's service plan included some evaluative information regarding the resident's current abilities and skills and physical abilities and limitations (the resident used reading glasses to see fine print, the resident was often confused, the resident needed reminders and physical escort to activities), the activity plan itself did not include instructions for adapting the activities to accommodate his/her needs (for example, that the resident should be wearing eyeglasses for certain activities). There was no evaluation of the resident's ability to use a pen or pencil, to follow multi-step instructions or to participate in physical exercise.

The need to ensure the facility evaluated each resident's current abilities and skills, physical abilities and limitations and adaptations necessary for the resident to participate, and developed an individualized activity plan for the resident based on the evaluation, was reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 07/2022 with diagnoses including dementia.

Observations of the resident and interviews with staff were conducted. The resident's current service plan and the "Resident Biography" were reviewed.

Observations in Cottage 4 revealed Staff 16 (Activity Assistant) inviting Resident 4 to an exercise group and an activity in various stages of painting pots and planting seeds. The resident declined both times.

An interview with Staff 16 on 03/08/23 at 10:40 am revealed the resident may participate in an activity for about 15 minutes and then would return to his/her room. Staff 16 did state Resident 4 liked to talk about his/her family.

There was no documented evidence the following elements were addressed in an activity evaluation:

* Current abilities and skills;

* Emotional needs and patterns; and

* Physical abilities and limitations.

Resident 4's service plan directed staff to provide escorts and reminders to and from activities. The service plan also specified the resident "requires assistance from staff to initiate, attend and participate in activities." Some of the resident's current interests included watching television, movies and football; walking; sitting and watching other residents; creative things; country music; and reminiscing about being with his/her family on Thanksgiving, being proud of his/her sons, and talking about his/her dog.

There was no documented evidence of how the facility would meet the resident's needs and implement those preferences in an individualized plan.

The need to ensure the facility evaluated each resident, which included all the required elements, and developed an individualized activity plan for the resident based on the evaluation, was reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23. They acknowledged the findings.

3. Resident 6 was admitted to the facility in 04/2020 with diagnoses including late onset Alzheimer's disease.

Observations made in Cottage 6 between 03/07/23 and 03/09/23 showed multiple group activities. Resident 6 did not participate in any of the activities nor did staff engage him/her in one-on-one activities or visits.

The facility failed to evaluate Resident 6's current abilities and skills. The facility did evaluate the resident's physical abilities and limitations (the resident had low vision and was hard of hearing) and his/her emotional and social patterns (the resident was not used to being in group settings and could benefit from one on one visits). However, the facility failed to use that information to identify adaptations necessary for the resident to participate in preferred activities. The resident's activity plan lacked specific instructions for providing activities that incorporated information gathered from the evaluation.

The need to ensure the facility evaluated Resident 6's current abilities and skills, and adaptations necessary for the resident to participate, and developed an individualized activity plan for the resident based on the evaluation, was reviewed with Staff 1 (ED) and Staff 2 (Resident Services Director) on 03/09/23. They acknowledged the findings.

The Cottages Senior Living Individualized will ensure  resident activity plans are developed based on resident evaluations.

The three resident activity plans mentioned in deficiency were updated to reflect current activity needs.

Weekly audits of resident activity plans will be completed by ED and RSD to assure compliance.  

Audits will be reviewed during Monthly Quality Assurance/Quality Measurment meetings to ensure compliance and evaluate internal system to keep in compliance.

All staff meeting will be held on April 10, 2023; training topic to include resident activity plans and service plans.

ED, RSD and Life Enrichment Coordinator will be responsible.   

Based on observation and interview, it was determined the facility failed to ensure fences surrounding the perimeter of the outdoor recreation areas were no less than six feet in height. Findings include, but are not limited to:

The facility was endorsed as a secure Memory Care Community for residents with a diagnosis of dementia. The building consisted of eight individual units, called "cottages," where residents resided. Each cottage had access to an outdoor recreation area.

Each of the outdoor areas were toured on 03/07/23. The iron fences surrounding Cottages 3, 4, 5, 6, 7 and 8 were less than six feet in height.

The fence heights were discussed with Staff 1 (ED) and Staff 3 (Maintenance Director) on 03/08/23. They acknowledged the fences surrounding those cottages were not six feet in height as required.

The Cottages Senior Living will comply with fencing surrounding the perimeter of the outdoor recreation areas will be no less than six feet in height.

Maintenance Director or Designee will fix the heighth of all fencing to be no less than six fee in height.

ED and Maintenance Director will be responsible.