The findings of the re-licensure survey conducted 01/09/23 through 01/11/23 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 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 revisit to the re-licensure survey of 01/11/23, conducted 05/16/23 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 and OARs 411 Division 004 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 01/09/23 at 10:25 am, the facility's kitchen was observed to need cleaning and/or repair in the following areas:

* Floors throughout the kitchen, including dry storage, had black matter build-up and food debris in corners, around perimeter edges and under equipment and shelves. The flooring had dark stains and/or dirt build up in multiple areas;

* Floors near the convection oven had numerous deep gouges of varying sizes and long deep gouges were noted near the prep areas and dish area;

* Cracked lids were noted on large dry storage bins in the back of the kitchen;

* Shelving and drawers throughout the kitchen and dry storage had food spills, white/gray accumulation, dust, and/or debris;

* Wall vents had a thick accumulation of lint and dust on the grates;

* Shelves in the refrigerator and freezer had spills, white accumulation, debris and mold. Debris was noted under shelves and fans and both units had thick gray dust on the grate covers;

* Baseboards near the dishwashing room and the back prep area were pulling away from the wall;

* Long dark streaks and spills were noted on the lower walls under the dishwashing equipment and a hole was noted in the wall around metal piping/water valves;

* Spills, splatters, chips, scrapes and/or debris were noted on walls, doors, doorframes and shelves;

* Debris was noted on storage shelves which held clean dishes, pots and pans;

* Cupboard surfaces, drawers and shelves in the beverage station area located outside the kitchen door had numerous dark stains, spills and debris. One drawer front was broken and sideways;

* A large wood counter's work surface had significant wear of the finish;

* One section of the hood vents over the stove was noted with a substantial layer of grease and dust accumulation;

* Multiple ceiling lights had dead insects, debris inside and were cracked with pieces of missing plastic; and

* A dirty grill attachment was hung on the wall in the prep area, multiple cupcake pans had a thick black accumulation over the entirety of the pan outside the cupcake holders, and a mid size pot had thick black accumulation on the bottom that was flaking off.

The need to ensure the kitchen was kept clean and in good repair was shown to and discussed with Staff 1 (ED) and Staff 11 (Director of Dietary Services) on 01/09/23. They acknowledged the findings.

1.  On 1/20/2023 Dining Director and team completed a deep clean of kitchen and beverage station areas including walls, shelves, vents, door frames, top surfaces and undercarriage of counters throughout the kitchen. Bids are pending for repair of damaged flooring near convection oven area, prep area, and dish room.  Cracked lids in large dry storage bins have been replaced.  Ceiling lights with debris, cracked with missing pieces were repaired.  All pots, pans and grill attachments that were not in good repair have been disposed of and new ones have been ordered.

2.  Dining Director has updated the kitchen cleaning schedule to assure areas mentioned in statement of deficiency are cleaned and monitored weekly.  Kitchen associates will be educated on the cleaning schedule as well as how to report an area in need of repair through the community work order process by 2/17/2023.

3. The Dining Director and/or a designee will verify that cleaning schedule is being implemented and completed daily, weekly, and monthly.  The Executive Director will complete a review of kitchen to monitor cleanliness during routine facility walk through.

4. The Executive Director and Dining Director are responsible for this plan of correction.  

2. Resident 2 was admitted to the facility in 10/2021 with diagnoses including osteoarthritis.

Observations of the resident, interviews with staff and Resident 2, review of the resident's 11/14/22 service plan, 11/20/22 through 01/09/23 progress notes, incident investigations and physician communications were completed.

a. The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Falls;

* Hallucinations and agitation;

* Skin tears and leg wounds; and

* Shoulder pain.

b. The resident experienced a fall which resulted in multiple rib fractures on 11/21/22. The resident additionally experienced a severe weight gain of 9.26% from 12/03/22 to 01/05/23. The significant changes of condition were not referred to the RN to complete a significant change of condition.

In interview on 01/10/23, Staff 2 (RN) indicated she was not aware of the resident's weight gain or rib fractures.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, resident-specific directions to staff, and significant changes of condition were referred to the RN for follow-up was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the findings.

3.  Resident 4 was admitted to the facility in 12/2014 with diagnoses including edema.

Observations of the resident, interviews with staff and Resident 4, review of the resident's 10/19/22 service plan, 11/09/22 through 01/06/23 progress notes, incident investigations and physician communications were completed.

a. The resident experienced multiple short-term changes without documented progress noted until resolved and/or lacked resident-specific directions to staff in the following areas:

* Medication changes;

* GI bleed; and

* Leg wounds.

b. The resident experienced a severe weight loss of 12/26% from 11/11/22 to 12/09/22. The significant change of condition was not referred to the RN to complete a significant change of condition.

In interview on 01/10/23, Staff 2 (RN) indicated she was not aware of the resident's weight loss.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, provided clear, resident-specific directions to staff and significant changes of condition were referred to the RN for follow-up was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to evaluate changes of condition, determine, document and implement interventions as indicated, provide resident-specific instructions to staff, evaluate the effectiveness of the interventions, document weekly progress until resolution, and/or notify the RN of significant changes of condition for 3 of 4 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 01/2019 with diagnoses including orthostatic hypotension and tremors.

Interviews with staff, review of the resident's 11/11/22 service plan, incident investigations, and 11/11/22 through 01/09/23 progress notes were completed.

a. The resident experienced short-term changes without documented progress noted until resolved in the following areas:

* 10/19/22: Left elbow skin tear; and

* 12/19/22: Scratch to the head.

On 01/10/23 Staff 3 (LPN) confirmed there was no documented progress noted for the skin injuries until resolved

b. Resident 3 was identified to have had a significant change of condition that included a 10% weight loss between 04/2022 and 10/2022.  The RN completed an assessment on 10/28/22. The facility did not update the service plan as needed related to the weight loss.

On 01/10/23 Staff 2 (RN) and Staff 3 (LPN) confirmed there was no update to the service plan related to the significant weight loss.

The need to ensure short-term changes of condition had documentation of weekly progress until resolution, and updates to the service plan with significant changes in condition was discussed Staff 1 (ED), Staff 2 and Staff 3 on 01/10/23. The staff acknowledged the findings.

1.Records for Resident 2, 3 and 4 were reviewed and updated accordingly.  The wound noted to Resident 3 head had resolved.

2.Resident records for those with a known pattern of skin issues, falls, behavior changes or significant weight change will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record.  Medication Technicians and Caregivers were educated on process for reporting skin concerns on 2/1/2023.  Associates will be educated on proper reporting of changes in condition by 2/17/2023.   Medication Technician associates and Community Nurse will be educated on change of condition documentation to reflect weekly monitoring until resolved.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.  If the change of condition is deemed significant, the community will refer to the community RN.  

3.Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance.

4.The Executive Director is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed timely, documented findings, resident status and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 2 and 4) who experienced significant changes of condition. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including osteoarthritis.

a. Weight records, dated 08/16/22 through 01/05/23 and progress notes dated 11/20/22 through 01/06/23, indicated the resident experienced a 10.4 pound weight gain from 12/03/22 to 01/05/23. This constituted a 9.26% severe weight gain in one month.

Multiple observations of the resident between 01/09/23 and 01/10/23 showed the resident was independent with his/her meal once it was delivered. The resident ate 75-100% of the meals observed. The resident had snacks and fluids available in his/her apartment. The resident was able to request additional items and maneuver around the facility independently. The resident walked to and from the dining room and common areas without assistance and was frequently seated in a recliner in his/her room with feet flat on the floor. The resident's lower legs appeared swollen and no wounds were observed.

In interviews between 01/09/23 and 01/11/23, Staff 3 (LPN) and Staff 7 (MT/CG) indicated the resident's intake was improved now and s/he was able to eat without assistance.

In interview on 01/09/23, Resident 2 indicated s/he received plenty to eat and could request more or different items as s/he chose to. The resident stated s/he had snacks available in their apartment and could get other items from the kitchen if s/he was still hungry. The resident indicated staff were very good about bringing him/her snacks and other foods if s/he did not make it down to the meal. The resident further stated s/he had been sick and uncomfortable a few months back but was doing better now and was having a particularly good day at the time of the interview. There were no concerns with his/her care or treatment by staff. The resident indicated s/he was supposed to elevate legs whenever possible to help with the swelling but was more comfortable seated with his/her feet on the floor.

b. The resident experienced two falls on 11/21/22 which resulted in skin tears to both arms, a trip to the emergency room, a hospital admission and multiple rib fractures.

Progress notes and physician communications dated 11/20/22 through 01/06/23 indicated the resident experienced multiple falls with and without injury and had a bout of COVID with increased weakness. The resident was admitted to the hospital for rib fractures from 11/21/22 through 11/23/22.  

Interview with Staff 2 (RN) on 01/10/23 indicated she was not made aware of the resident's weight gain until the time of survey. She was not aware the resident had sustained multiple rib fractures in November until the survey team questioned. Staff 2 stated she was not scheduled to be in the building on a specific day and was not routinely in the facility. Staff 2 stated she did not complete a significant change of condition for the weight gain and the rib fractures.

The facility failed to ensure an RN assessment was completed for the weight gain and the rib fractures which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the findings and understood the need for communication to the RN.

2. Resident 4 was admitted to the facility in 12/2014 with diagnoses including edema.

Weight records, dated 08/12/22 through 01/06/23 and progress notes dated 11/09/22 through 01/06/23, indicated the resident experienced a 12.4 pound weight loss from 11/11/22 to 12/09/22. This constituted a 12.26% severe weight loss in one month. The resident was currently on weekly weights and records showed the weights trended upwards and were stabilizing.

Multiple observations of the resident between 01/09/23 and 01/10/23 showed the resident was independent with his/her meal once it was delivered. The resident ate 75-100% of the meals observed. The resident had snacks and fluids available in his/her apartment. The resident was able to request additional items and maneuver around the facility independently. Bandages were noted on both of the resident's lower legs in addition to taut, red skin with some swelling noted. There was no sign of drainage. The resident wheeled him/herself to and from the dining room and common areas utilizing his/her feet.

In interviews between 01/09/23 and 01/11/23, Staff 3 (LPN) and Staff 7 (MT/CG) indicated the resident's intake had improved now and s/he was able to eat without assistance. Staff 3 stated the resident had mighty shakes three times a day between meals and had altered diet textures per his/her preference to help with easy intake. The resident had chronic leg wounds which would open and close related to edema as well. The staff both indicated the resident was able to make his/her needs known, direct their own care, and was independent with the majority of ADLs.   

In interview on 01/09/23, Resident 4 expressed no concerns with his/her care or staff assistance. The resident indicated s/he received plenty to eat and requested that staff puree all the items of choice together in one dish. The resident indicated s/he had shakes several times a day, snacks and the regular meals. Sometimes his/her appetite wasn't great, but s/he always tried to eat and drink something.

Interview with Staff 2 (RN) on 01/10/23 indicated she was not made aware of the resident's weight loss and additional health changes until the time of survey. Staff 2 stated she was not scheduled to be in the building on a specific day and was not routinely in the facility. Staff 2 stated she did not complete a significant change of condition for the weight loss or review other health changes at the time they occurred.

The facility failed to ensure an RN assessment was completed for the weight loss which documented findings, resident status and interventions made as a result of the assessment.

The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the findings and understood the need for communication to the RN.

1.  The records of Residents 2 and 4 have been reviewed and updated as it relates to their significant change of condition.

2.  Resident records for those with a known pattern of significant weight changes will be reviewed to assure proper evaluation, preventative measures as appropriate and documentation is reflected in the resident record and service plan.  Associates will be educated on proper reporting of changes in condition and related documentation by 2/17/2023.  Health & Wellness Director will be educated on when to refer to the community RN for significant changes in condition and the requirement for weekly monitoring until resolved.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, documentation is reflected in the resident record and updates are made to the service plan as appropriate.  If the change of condition is deemed significant, the community will refer to the community RN.  

3.  The Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance.

4.  The Executive Director and Registered Nurse will be responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to coordinate on-site health services with outside providers, ensure outside providers left written information in the facility that addressed on-site services being provided, and reviewed and updated the resident's service plan with new interventions, for 2 of 2 sampled residents (#s 2 and 4) who received home health services. Findings include, but are not limited to:

1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including osteoarthritis.   

During the acuity interview on 01/09/23, Resident 2 was identified as receiving outside provider services related to physical therapy.  

Observations of the resident, interviews with staff, review of the service plan dated 11/14/22, progress notes and outside provider notes dated 11/20/22 through 01/08/23 were completed. The resident experienced multiple falls and had some weakness noted.

The resident received physical therapy services weekly related to fall risk and strengthening.

On 12/21/22 physical therapy notes indicated balance and transfers at bedside were addressed after a recent fall. The PT made a recommendation that the resident would benefit from a bedside rail or cane to help with safety.

There was no documentation the recommendation was reviewed for implementation as an intervention for resident safety as indicated by PT.

The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the findings.

2. Resident 4 was admitted to the facility in 12/2014 with diagnoses including edema and chronic leg wounds.    

During the acuity interview on 01/09/23, Resident 4 was identified as receiving outside provider services related to skilled nursing for wound care.   

Observations of the resident, interviews with staff, review of the service plan dated 10/19/22, progress notes and outside provider notes dated 11/09/22 through 01/06/23 were completed. The resident was noted with multiple small open wounds to both lower legs with bandages in place.

The resident received skilled nursing services for wound care twice a week. The most recent leg wounds reopened on 12/08/22. Home health wound care began 12/10/22. Two notes from home health nursing visits were available in the resident's record between 12/10/22 and 01/06/22. No other notes were on site.

The need to ensure on-going coordination of care documentation was provided with each visit was discussed with Staff 1 (ED), Staff 2 (RN) and Staff 3 (LPN) on 01/10/23. The staff acknowledged the visit notes were not left at the facility.

1. Documentation received from outside providers for Resident 2 and 4 were reviewed and resident records updated to reflect services and recommendations.  Outside providers were educated on community procedures for reporting to community staff at the conclusion of their visit.

2. Provider notes from the last 30 days for remaining residents receiving outside services will be reviewed to assure recommendations made were communicated to staff and updated on each service plan.  Outside provider notes will be reviewed daily in conjunction with the triple check order process during the clinical meeting to assure actions are taken as necessary.  A clinical white board will be used to track residents receiving outside services and updated at the conclusion of the clinical meeting.

3.Executive Director and/or designee will randomly audit 4 resident records weekly for 60 days to assure ongoing compliance.

4.The Executive Director and Health & Wellness Director will be responsible for this plan of correction.