The findings of the re-licensure survey, conducted 01/08/24 through 01/11/24, 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, 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. Tag numbers beginning with the letter H refer to the Home and Community Based Services 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 revisit to the re-licensure survey of 01/11/24, conducted 07/31/24 through 08/01/24, 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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:

Observations of the main kitchen and dining room service area were conducted on 01/08/24, 01/10/24, and 01/11/24.

a. An accumulation of food spills, splatters, loose food, dirt, dust, and/or black matter was visible on or underneath the following:

* Multiple service carts were visibly dirty;

* Left side of the stove/oven (next to the fryer);

* Interior/exterior of ovens;

* Interior/exterior of fryer and underneath the fryer had a build-up of grease;

* Juice machine and tray had a build-up of dried juice in and around the nozzles;

* Floor drains underneath the warewasher, three compartment sink, and juice machine;

* Ceiling vents and ceiling tiles (between the ovens and steam table); and

* Multiple garbage cans lacked covers when not in use.

b. The following areas were in need of repair:

* The Beverage Air salad cooler was inoperable.

c. Food storage:

* Multiple food items in the reach-in refrigerator, walk-in freezer, and reach-in freezer next to the fryer were opened and uncovered; and

* There were open food items in the dry food storage area.

The kitchen was toured and discussed with Staff 1 (MC Administrator), Staff 4 (Campus Administrator), Staff 13 (Dining Services Director), and Staff 14 (Assistant Administrator) on 01/11/24. They acknowledged the findings.

1. Kitchen received deep clean day of inspection to address service carts, ovens including all vertical and horizontal surfaces. The fryer was cleaned to address all surfaces surrounding and including fryer with degreaser. Juice Machine was cleaned. Floor Drains were cleaned. The tile and vents were cleaned. Trash cans with lids to be purchased and placed. The Beverage air salad cooler is not in use currently by any staff member. All Food in the Freezer next to the fryer will be covered and properly labeled at the end of meal service and placed in the reach in fridge and freezer to prevent cross contamination and frost burn. Food in the walk-in fridge and freezer were immediately covered and labeled on 1/11/24. Dry Foods were addressed immediately and covered properly on 1/11/24. 2. All cleaning schedules will be overseen by DSD. Audits for cleanliness will be performed as indicated below. Walk in Fridge and Freezer as well as Dry Food area will have bimonthly audits to ensure proper food storage. 3.Carts are now on daily wipe down cleaning list in addition to monthly detailing schedule by DSD or Sous chef oversight. The stove and oven will be wiped down daily by line cook. Sous chef to deep clean stove, oven, and line every Wednesday including all vertical and horizontal surfaces. The fryer will be clean and filtered daily by line cook. Oil to be changed every Tuesday and Saturday. Fryer will be "boiled" out monthly by DSD. Inside and outside of Fryer with all removeable attachments to be cleaned monthly with degreaser. Juice machine will be taken apart and cleaned daily by server staff. DSD to perform bi-weekly checks to ensure cleanliness. Floor Drains will be checked weekly by DSD for buildup and cleaned monthly and as needed by DSD or Sous chef to prevent build up. Ceiling tiles and vents to be checked daily by line cook. DSD to clean monthly and as needed. Garbage cans to be randomly checked to ensure lids are placed appropriately. Beverage air cooler will be serviced or disposed of by 3/11/24. If disposed of it will be discarded properly under all applicable state and county laws and codes. Food in the freezer next to the fryer will be properly labeled and stored in a walk-in freezer at the end of meal service. Freezer and walk-in fridge training was provided on 1/11/24 and 1/12/24 covering all "cooks" in the kitchen on proper label and covering guidelines. DSD to perform audit of Fridge and Freezer bi-monthly to ensure compliance. Dry storage training was provided on 1/11/24 and 1/12/24 on proper covers in the Dry Food area. DSD to provide bi-monthly audits to assure compliance.  4. Administrator and DSD will do monthly walk through of kitchen area to ensure compliance with all deficiencies are being met.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding care and services for 1 of 2 sampled residents (#1 ) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 03/2022 with diagnoses including dementia and type two diabetes.

Observations of the resident, interviews with staff, and review of the most current service plan, dated 01/04/24, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas:

* Frequency of home health visits and services provided;

* Care instructions for Foley catheter, including using a securement device and placing collection bag below bladder level;

* Full meal assistance provided in bed, including aspiration and choking precautions;

* Routine denture care and oral hygiene;

* Use of air mattress; and

* Preference for bottled water from personal refrigerator.

The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (MC Administrator) on 01/11/24. She acknowledged the findings.

1. Wellness Director, Administrator, Resident Care Coordinator, will read each care plan to ensure accuracy of task performed and Care giver instructions.To be performed on all care plans.  Frequency, of home health visits, instructions for foley cathether,  Instructions for feeding resident his meals in bed (including precautions), instructions on oral care/ denture care, precaustions for air matress and preferences added to care plan for mentioned resident.  2. Moving forward Wellness Team to perform 2 random Care plan audits utilizing care plan audit forms. 3. Care plan audits will be performed monthly. See exhibit A. 4. The Wellness Director will ensure audits are being done as listed above.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 1 sampled resident (#1) whose medication orders were reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 03/2022 with diagnoses including dementia and type two diabetes.

Resident 1's 12/01/23 through 01/09/24 MARs, corresponding progress notes, and current physician orders were reviewed.

The resident had a physician's order to receive a nutritional shake three times a day. Records revealed the order for the nutritional shake was not carried out as prescribed on the following dates:

* 11/18/23;

* 11/19/23;

* 12/23/23;

* 12/27/23;

* 12/28/23;

* 12/29/23;

* 12/30/23;

* 01/01/24;

* 01/02/24;

* 01/03/24; and

* 01/05/24.

There was documentation on the MAR for each of these dates stating, "currently out of [nutritional shakes] waiting for delivery."

During an interview on 01/11/24 with Staff 1 (MC Administrator), she confirmed the resident had not received the nutritional shakes as prescribed on the above dates.

The need to ensure physician orders were carried out as prescribed was discussed with Staff 1, Staff 4 (Campus Administrator), Staff 5 (Wellness Services Director/LPN), and Staff 6 (RN) on 01/11/24. They acknowledged the findings.

1. Audit was performed on the medication cart to ensure we had "Mighty Shakes". 2. Wellness Director to order "Mighty shakes" and ensure we have one box of mighty shakes on hand at any given time. If "mighty shakes" are on back are on back order. Administrator to purchase at local vendors. Weekly Audits of refusals and missed meds to be performed. See Exhibit B Monthly Audits to med carts to be performed. See Exhibit C.  3. Weekly Audits of missed medications to be performed by wellness team. Monthly audits of medication carts to be performed by RCC. Follow ups to be performed immediately. 4. Wellness Director to oversee all corrections have been completed utilizing audit tools.

Based on interview and record review, it was determined the facility failed to ensure residents' MARs were accurate and provided medication-specific instructions for 1 of 1 sampled resident (#1) whose MAR was reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 03/2022 with diagnoses including dementia and type two diabetes.

Resident 1's 12/01/23 through 01/09/24 MARs and physician orders were reviewed.

Resident 1 had physician orders for:

* Calmoseptine ointment to be applied to "affected areas" three times a day;

* Nystatin powder to be applied to "affected areas" three times a day; and

* Triamcinolone cream to be applied to "affected areas" two times a day.

The MARs lacked medication-specific instructions for unlicensed staff as to the affected areas each of the treatments were to be applied.

The need to ensure a resident's MAR included medication-specific instructions was reviewed with Staff 1 (MC Administrator) on 01/11/24. She acknowledged the findings.

1. Wellness team to do a deep dive into all resident MAR's ensuring accuracy. 2. Staff training provided on 1/14/24 to educate staff about "affected area" instruction. Third checks updated to include direction and clarification from LN where appropriate. Monthly medication cart audits to be performed by wellness team. The Wellness Team will perform in depth audit of two residents' monthly analysis on treatments to ensure staff compliance and accuracy. 3. Monthly and as needed. See Exhibit C.  4. Wellness Director.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with Oregon Fire Code (OFC) and included all required components. Findings include, but are not limited to:

Fire drill and fire and life safety records were reviewed from 06/2023 through 12/2023. The following deficiencies were identified:

a. The facility failed to document the following required components:

* Escape route used;

* Problems encountered, comments relating to residents who were unwilling to participate in the drills;

* Staff members on duty and participating;

* Number of occupants evacuated; and

* Evidence alternate routes were used during each fire drill.

b. During the 12/28/23 fire drill the facility documented three residents didn't participate in the fire drill. The following deficiency was identified:

* There was no documented evidence of what changes were made to ensure the evacuation standard was met.

Fire and life safety instruction and the required fire drill components were reviewed with Staff 1 (MC Administrator) and Staff 11 (Maintenance Director) on 01/09/24. They acknowledged the findings.

1. Updated fire drill form used when completing fire drills. 2. The Maintenance Director updated the fire drill forms to include the following information: escape route, problems encountered, staff members on duty, participants, number of residents evacuated, alternate routes. See Exhibit D. 3. Forms to be reviewed quarterly to ensure compliance. 4. Maintenance Director and Administrator to audit quarterly for accuracy and compliance.

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 C 240 and C 420.

Refer to C 240, and C 420.

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, C 303, and C 310.

Refer to C260, C 303 and C 310.  

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 2 of 2 sampled residents (#s 1 and 2). Findings include, but are not limited to:

Service plans for Residents 1 and 2 were reviewed during the survey. Although the service plans provided some information regarding food preferences, they lacked information and staff instructions related to individualized nutrition and hydration status and needs.

The need to develop individualized nutritional plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (MC Administrator) on 01/11/24. She acknowledged the findings.

1. Nutritional Evals to be completed by Wellness Team. 2. Move in process to include nutritional evaluation process and included in all care plans moving forward. 3. Nutritional Evaluations to be performed quarterly and as with all service plan meetings. 4. Monthly audits to ensure all Nutritional Evaluations are completed to be performed. Wellness team to choose two random residents monthly to perform care plan audits which include nutritional information. Wellness Director to oversee and ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose records were reviewed. Findings include, but are not limited to:

Although Resident 1 and 2's service plans offered some information about the resident's interests, the facility had not fully evaluated the residents':

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Activities that could be used as behavioral interventions, if necessary.

There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the residents with more individualized activities.

The need to ensure each resident was evaluated and an individualized activity plan was developed was reviewed with Staff 1 (MC Administrator) on 01/11/24. She acknowledged the findings.

1. Life stories are being done with residents and will be completed by 1/31/23. Care Plans have been updated to include current abilities, emotional and social needs, physical abilities and limitiations, any adaptaions needed, behavioral activies. Care Plans now include who and what staff and how often staff to perform the above. 2. Facility will utilize "Life Stories evaluation, Behavioral Evaluation and Care Plan assessment to create activity plans for each resident. 3. These assessments are to be reassessed with each Care Plan meeting and as needed. Care Plan meetings are held quarterly and with any SCOC. 4. Wellness Team to Audit assessments needed Monthly to ensure compliance.

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

A tour of the MCC courtyard on 01/09/24 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 68 inches.

On 01/11/24, the need to ensure that fencing was no less than six feet was discussed with Staff 1 (MC Administrator), Staff 4 (Campus Administrator), Staff 5 (Wellness Services Director/LPN), and Staff 6 (RN). They acknowledged the findings.

1. The Maintenance Director is in the process of gathering bids to apply Trellis panels for height to the fence. 2. These panels will be installed no later than 3/11/24. 3. Fence to be measured two times yearly to ensure fence remains above 6 feet. 4. Maintenance Director to perform measurements and report to Administrator.