The findings of the re-licensure survey, conducted 08/08/23 through 08/09/23, 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 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 revisit to the re-licensure survey of 08/09/23, conducted 12/20/23, are documented in this report. It was determined the facility was in substantial compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure 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 on 08/08/23 revealed:

* Scraped and gouged door jambs;

* Sections of caulking missing from behind the sink next to the stove;

* Food debris, matter and trash in several cupboards and drawers;

* Dried food matter on several drawer and cupboard handles;

* A layer of dust covering the ice machine vent;

* Gouges and scrapes on the wall across from the dish machine;

* Food splatters on the ceiling near the main entrance; and

* Universal Workers, who assisted residents with ADL care, did not consistently use aprons or have hair restrained when serving food.

The food handling concerns, and areas in need of cleaning and repair were reviewed with Staff 1 (Administrator) and Staff 5 (Lead Cook) on 08/08/23. They acknowledged the findings.

C240 OAR 411-054-0030 (1)(a)

Resident Services meals, Food sanitation Rule

1. Actions to be taken to correct the rule violation include:

Scraped and gouged door jams were painted, and caulking was completed. Ceiling was cleaned along with cleaning of kitchen drawers, cupboards,  cupboard handles, and cleaning of ice machine. A task sheet has been put in place for cleaning of such items in the kitchen for staff to follow. This will ensure cleaning is kept up on.

B. Staff will be closely monitored by Administrator for all meal distribution to the residents. To ensure that cross contamination is not happening for the safety to all. Staff meeting to retrain staff on aprons and hair nets, and/or pulled back hair when serving food.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to:

Observations of the outer courtyard surfaces and pathways on 08/09/23 showed the following:

* Multiple drop-offs of 2-3 inches along several pathway edges.

The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 3 (Maintenance) during a tour of the exterior grounds on 08/09/23 at 11:00 am. The findings were acknowledged.

C610 OAR 411-054-0300 General building exterior

1. Actions to be taken to correct the rule violation include: Landscapers had been contacted for the said drop offs. They were fixed immediately on 8/10/2023 with fill dirt. Scheduled for red rock on 8/21/2023 to keep drop offs secure. This has been completed. Additionally awaiting bid for outside perimeter drop offs for river rock to complete exterior pathway edges.

A. Moving forward maintenance will monitor these areas for any drop offs after weekly yard maintenance from landscapers.

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

Observations of the facility on 08/09/23 revealed the following:

* Resident rooms 102, 105, 113, 120, 124 had scraped doors and/or jambs;

* The door jamb to the hopper room and beauty shop had scraped and gouged areas; and

* Multiple chairs in the dining room and television room had stained seat cushions.

The surveyor toured the environment with Staff 3 (Maintenance) on 08/09/23 at 11:00 am. He acknowledged the findings.

Areas needing cleaning and repair was discussed with Staff 1 (Administrator) and Staff 3 on 08/09/23 at 11:10 am. The findings were acknowledged.

C613 OAR 411-054-0300 (4)(d-i) General Building: Doors- Walls,Cleanable

1. Actions to be taken to correct the rule violation include: Resident's room doors 102, 105, 113, 120, and 124 were cleaned and paint touched up along with beauty shop door, and hopper room door. To make sure it is kept up housekeeping & maintenance will inspect as they are getting their rooms cleaned on the scheduled day of cleaning of any touch ups needed.

A. New chairs have been ordered  for the dining room, and television area. We have ordered cleanable surface material to make easy clean-up.