The findings of the re-licensure survey, conducted 03/07/22 through 03/08/22, 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, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 for Home and Community Based Services Regulations.
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 03/08/22, conducted 05/11/22, 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 57 for Memory Care Communities.
Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living 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 second re-visit to the re-licensure survey of 03/07/22, conducted 08/03/22, 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, and OARs 411 Division 57 for Memory Care Communities, 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 kept clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:
On 03/07/22 and 03/08/22, the facility's kitchen was observed to need cleaning or repair in the following areas:
* Floors throughout the kitchen, including dry storage, walk-in refrigerator, freezer, and underneath the beverage station had black matter build-up and food debris in corners, around perimeter edges, under equipment, and inside floor drains;
* Flooring that ran up the walls to form baseboard was pulling away from the wall in multiple areas;
* The juice dispenser had a metal shelf with chipped paint, and rust had developed around the rim where the shelf attached to the machine;
* Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, dust, and debris;
* Ceiling vents had an accumulation of lint and dust on the grates;
* Ceiling lights had smears and spills on the inside of the covers;
* Walk-in freezer had multiple items on the floor and food boxes hanging off shelves in piles;
* Flooring in the main kitchen had multiple dings, gouges and black discoloration;
* Doors, door frames, and walls had spills, chips, and dings, and plastic corner pieces around the windows and edges of the back wall were broken in multiple areas; and
* Muffin baking pans were covered in a thick, black, cooked-on substance.
The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 2 (ALF Executive Director) and Staff 5 (Interim Dining Services Director) on 03/07/22 and 03/08/22. The staff acknowledged the findings.
The following corrections will be made for each found concern:
*Floors throughout the kitchen, including dry storage, walk-in refrigerator, freezer, and underneath the beverage station had black build-up. This will be corrected by having all the flooring replaced in the kitchen. Flooring is old and is beyond repair/cleaning improvements. Staff will be retrained to ensure that while mopping if the mop is not able to fit in the corners, the corners will need to be cleaned by hand. Staff will be retrained on ensuring that sweeping is done between every meal to ensure that floor debris is kept to a minimum. Executive Chef will implement a cleaning schedule and audit weekly.
*The juice dispenser had a metal shelf with chipped paint, and rust had developed around the rim where the shelf attached to the machine. This will be corrected by contacting our juice vendor to have a new juice tray brought in. If unable to replace tray a new machine will be brougt in.
*Shelving throughout the kitchen, including the walk-in refrigerator and freezer, and shelving in the dry storage had food spills, dust, and debris. This will be cleaned and the Executive Chef will implement a cleaning schedule and audit weekly.
* Ceiling vents had an accumulation of lint and dust on the grates and the overhead light covers were dirty. This will be cleaned and Executive Chef will implement cleaning schduled and audit weekly.
*Walk-in freezer had multiple items on the floor and food boxes hanging off shelves in piles. Staff will be retrained on Food Sanitation including food storage. Walk-in and freezer will be organized. Executive Chef will implement cleaning schdule that will include to ensure walk-in and freezer are organized, with everything up off the floor nightly. Executive Chef will audit 3x a week.
*Doors, door frames, and walls had spills, chips, and dings, and plastic corner pieces around the windows and edges of the back wall were broken in multiple areas. FPR Board will be replaced in the kitchen due to it being beyond repair and free of stains. Executive Chef will implement a cleaning schdule to ensure after new FPR board in installed that it remains clean and free of stains. This will be audited weekly.
*Doors have also been ordered for replacement. Executive Chef will implement a cleaning schdule to ensure doors will remain clean and free of chips. All findings will be reported to the Environmental Services Director and Executive Director.
*Muffin baking pans were covered in a thick, black, cooked-on substance. This was corrected by Executive Chef and all pans/pots that needed to be replaced were replaced. This will be audited weekly by Executive Chef.
There are no detail notes for this visit.
Based on interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:
Refer to C 510 and Z 173.
This tag will be resolved once we are cleared for the outdoor courtyard fence and edging has been raised along sidewalk in courtyard. All other tags from initial survey have been completed. ESD/ED will follow-up with contractor to notify him of 6/25 deadline.
Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. Findings include, but are not limited to:
Observations of the secure courtyard on 03/07/22 showed there were multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the courtyard.
The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 (MC Executive Director) and Staff 3 (Environmental Services Director) on 03/07/22. They acknowledged the findings.
There were multiple drop-offs of 2-4 inches along pathway edges and sitting areas in the courtyard. This will be corrected by having our landscapers and filling in all gaps and drops around all sidewalks. Landscapers will be educated on RCF regulations to include the edging. Environmental Services Director will check monthly to ensure there are no large gaps.
Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:
A tour of the facility courtyard with Staff 1 (MCC Executive Director) on 05/11/22 showed there were multiple drop-offs of 2-3 inches along pathway edges and sitting areas in the courtyard.
The need to ensure pathways in the resident courtyard did not have potential safety hazards was discussed with Staff 1 on 05/11/22. She acknowledged the findings.
Environmental Services Director will work with landscapers to fill the gaps along entry outback and along sidewalk. This will be checked monthly by ESD/MCD to ensure that landscapers are not trimming too low.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to:
Observations of the facility on 03/07/22 and 03/08/22 showed the following areas in need of cleaning or repair:
* There were spills and debris on cupboard shelves and inside drawers, and chipped cabinet doors with missing laminate;
* Multiple dining room chairs and one upholstered chair had white and red spills/stains on the seats and backs;
* Wooden handrail near room 112 had a large, approximately four inch piece of chipped wood with a sharp splinter exposed. The handrail was wrapped loosely in gauze;
* Walls and window sills in the dining room had spills, splatters, and dings; and
* The oven located in the dining room had black spills and debris on the bottom of the oven and inside the lower drawer.
The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (MC Executive Director) on 03/08/22. She acknowledged the findings.
*There were spills and debris on cupboard shelves and inside drawers, and chipped cabinet doors with missing laminate. This will be corrected by replacing cabinet doors. Environmental Services Director will audit the new cabinets monthly to ensure they are in good shape. Memory Care Director will audit weekly to ensure that cabinets are clean, organized,and free of debris.
* Multiple dining room chairs and one upholstered chair had white and red spills/stains on the seats and backs. This will be corrected by having our vendor come in and professionally clean all furniture. Furniture that is unable to have stains removed will need to be removed and/or replaced. Memory Care Director will audit weekly to ensure that all furniture is free of stains and odors.
*Wooden handrail near room 112 had a large, approximately four inch piece of chipped wood with a sharp splinter exposed. The handrail was wrapped loosely in gauze. New handrails were purchased and will be installed. New handrails are medical grade plastic/vinyl. Housekeeping will clean handrails daily and as needed. Memory Care Director will check handrails monthly to ensure there are no concerns or safety issues.
*Walls and window sills in the dining room had spills, splatters, and dings. This will be corrected by ESD cleaning and repainting needed areas. Memory Care will audit weekly to ensure that caregivers and/or housekeeping are cleaning walls, door jams/doors, and window sills to keep them free of debris. Any findings will be reported to the Environmental Services Director.
*The oven located in the dining room had black spills and debris on the bottom of the oven and inside the lower drawer. This will be corrected by our Lifestyle Director cleaning oven and drawer. This will be prevented by having Lifestyle Director/Memory Care Director clean oven on a monthly basis and as needed.
There are no detail notes for this visit.
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 provide security and to alert staff when residents exited the building. Findings include, but are not limited to:
Observations on 03/07/22 and 03/08/22 showed exit doors to the resident courtyard 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 (MC Executive Director) on 03/07/22 and 03/08/22. She acknowledged the findings.
Exit doors to the resident courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building. This was corrected by purchasing a 'dinger' that was attached to the top of the doors. This 'alarm' will sound each time the door is opened, to alert the staff that the door to the courtyard has opened. Environmental Services Director will audit sparadically no less than monthly to ensure it is in good working condition.
There are no detail notes for this visit.
Based on observation, interview and record review, 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 C240, C510, C513, and C555.
It was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Refer to C240, C510, C513, and C555. This will be corrected by ensuring that all above tags have been resolved. This will be completed by the Executive Director. Executive Director will meet weekly with all Department Managers (assisted living and memory care) involved to ensure all audits are completed.
Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:
Refer to C 510.
This tag will be resolved once the grounds in memory care clear survey.
There are no detail notes for this visit.
Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height. Findings include, but are not limited to:
A tour of the facility courtyard on 03/07/22 showed multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 5 feet 8 inches.
The fencing sections that were less than six feet in height were discussed with Staff 1 (MC Executive Director) and shown to Staff 3 (Environmental Services Director) on 03/07/22. They acknowledged the findings.
Multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 5 feet 8 inches. This will be corrected by leveling the ground to eliminate the 'mounds' that cause the fence to be too short and/or add a latice style material to the top of the fence to ensure compliance is met. Environmental Services Director will check quarterly to ensure fencing is in compliance. Spots will be at random. Any findings that do not meet regulation will be reported to the Executive Director.
Based on observation and interview, it was determined the facility failed to ensure that fencing was no less than six feet in height. This is a repeat citation. Findings include, but are not limited to:
A tour of the outdoor courtyard was conducted with Staff 1 (MC Executive Director) on 05/11/22 and showed multiple sections of fencing around the perimeter of the secured outdoor area were less than six feet in height. The shortest sections were approximately 5 feet 8 inches.
The fencing sections that were less than six feet in height were discussed with Staff 1 on 05/11/22. She acknowledged the findings.
Contractor is scheduled to come and move the fence that is below 6ft and place it around the tree to ensure that it is at least 6ft tall. ESD will check height of fence quarterly due to ground settling to ensure the safety of our residents and that we are in compliance of OARs.