Print Inspection: GF36

The findings of the re-licensure survey, conducted 05/09/22 through 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 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 re-visit to the re-licensure survey of 05/11/22, conducted on 09/27/22, 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.

b. During the acuity interview on 05/09/22 at approximately 9:35 am, the facility identified residents with diagnosis including dementia living in the assisted living community.

The kitchens in Aspen and Dogwood buildings were toured on 05/09/22 between 10:30 am and 11:15 am.

There were cleaning chemicals being stored in unlocked cupboards below the sink in both kitchens. The kitchens were unsecured and next to a common area where residents moved about freely, which posed a risk of harm to the residents.

The need to ensure there was locked storage for all chemicals was discussed with Staff 1 (Executive Director) on 05/09/22 at 11:20 am. He acknowledged the findings.

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:

a. Observations were made during the survey to determine adherence to universal precautions.

On 5/10/22, the surveyor obtained permission and observed a CG providing incontinent care to Resident 3. During the observation, the CG failed to change their protective gloves after providing perineal care to the resident and proceeded to touch the resident's clean incontinence supplies with the same soiled gloves. The CG removed their gloves after changing the supplies.

The surveyor instructed the CGs on appropriate infection control procedures and the importance of hand hygiene when providing care to residents.

On 5/11/22, the above observations and the need to ensure universal precautions for infection control were followed was discussed with Staff 2 (Health Services Administrator). She acknowledged appropriate infection control practices were not implemented.

a. Caregiver in question was spoken to and understands the importance of changing gloves after providing perineal care. Additional training to be given to all health services staff by Administrator at next staff meeting on 6/7/22. Moving forward, this will be something that is monitored at 30 day evaluations by Administrator or other trained staff.

b. Cabinets with chemicals had locks but no keys. All cabinets were re-keyed and are locked. This was done prior to the survey team leaving the community. All staff to check the cabinets when on their shifts to confirm they are locked.  

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:

On 05/09/22 between 9:30 am and 11:15 am, the main kitchen and two small kitchens, (Aspen and Dogwood buildings), were toured and observed to need cleaning and repairs in the following areas:

1. Areas identified as needing cleaning included food spills, splatters, buildup of debris, dust, and black matter on or underneath the following:

a. Main kitchen

* All floor surfaces including beneath the dishwasher, ice machine and steam table;

* The drain underneath the dishwasher;

* Pipes beneath the dishwasher and sinks;

* Food warming area and food prep table;

* Inside the microwave;

* All window blinds and sills. There was dust buildup and dead insects on a windowsill in a dry food storage room;

* Air conditioning unit;

* Ceiling vents;

* The oven grills, burners and inside the oven;

* Surface of the light switch by the kitchen entrance;

* Fans in the refrigerator;

* Inside a knife drawer;

* Hot food carts; and

* Baseboards and walls.

Main Kitchen, additional observation pertaining to proper food storage:

* In the main kitchen freezer, frozen meat and other frozen food items were stored on the floor. The items were relocated by staff at the request of the surveyor.

a. Aspen building kitchen, areas identified as needing cleaning;

* Inside the oven:

* Inside the microwave;

* Inside and outside of all cabinets and inside drawers:

* Inside the refrigerator;  

* The industrial can opener;

* The metal food warmers;

* Floor surface in the dry food storage room.

c. Dogwood Building kitchen, areas identified as needing cleaning:

* Inside the microwave;

* Inside all drawers;

* Metal food warmers;

* Inside refrigerator;

* The floor surface by the dishwasher;

* Industrial can opener;

* Inside the oven;

* Inside floor surface of the cupboard underneath the sink; and

* The area above the ice machine.

2. The following areas were observed as needing repairs:

a. Main kitchen

* Exposed sheetrock in multiple areas including underneath all sinks;

* Floor panel molding located outside dry food storage room.

* Scraped and peeling paint in multiple areas including door jams; and

* Wooden door frame panels had chips, cracks, and gouges with exposed wood.

a. Aspen building kitchen

* Outside of wooden cabinets and wood surfaces had scrapes, chipping and gouges; and

* Floor molding was cracked.

b. Dogwood building kitchen

* Outside of wooden cabinets and wood surfaces had scrapes, chipping and gouges; and

* A pipe underneath the sink was leaking. A plastic container placed below the pipe was filled with dark brown water and there was pooled water on the floor surface under the sink.

The need to ensure the kitchen was clean and maintained in accordance with the Food Sanitation Rules OAR 333-150-000 was discussed and the kitchen was toured with Staff 1 (Executive Director) on 05/09/22  at 11:20 am. He acknowledged the findings.

1. A cleaning team  brought in to deep clean all kitchens including but not limited to: ovens, microwaves, cabinets, drawers, floors, ice machines, food carts, window sills, baseboards, walls and appliances.

Any food items that were stored on the floor of the freezer were relocated at the time of survey.

2. Walls and doors will be repainted and corner protectors added as needed.

Cabinets will be sanded, guages filled and restained or painted or .

Leaking pipe and exposed sheetrock to be fixed by Director of Plant Ops.

Cracked floor panels to be repaired or replaced by the Director of Plant Ops.

Director of food and beverage services will monitor on a monthly basis for any repairs needing to be made and weekly for cleanliness. Kitchen staff to make sure that they are wiping down every surface after each shift.

Director of Plant Ops or Executive Director will walk the kitchens weekly to look for exposed areas that may need repair.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:

Fire and life safety records for 12/2021 through 04/2022 were reviewed and lacked the following components:

* Documented evidence fire and life safety training was conducted on alternating months of fire drills;

* Escape routes used;

* Problems encountered or comments relating to residents who resisted or failed to participate in the drills;

* Number of residents evacuated;

* Alternate exit routes used during fire drills to react to varying potential fire origin points; and

* Identifying residents who were unwilling or failed to participate in fire drills and a documented plan to make an immediate effort to make changes to ensure the evacuation standard was met.  

The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) and Staff 7 (Plant Operations Director) on 05/10/22 and 05/11/22. They acknowledged the findings.

Fire and life safety is performed by Plant Operations. All fire drills and and corresponding documentation has been done as required however, documentation was lacking. Director of Plant Ops reviewed this with his team and showed them proper documention that is needed and how to complete it. He will be reviewing them as they are done to assure completion.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were met. Findings include, but are not limited to:

Fire drill records from 12/2021 through 04/2022 were reviewed. The facility lacked documentation that residents were being instructed on fire and life safety procedures within 24 hours of admission and annually.  

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Administrator) and Staff 7 (Plant Operations Director) on 05/10/22 and 05/11/22. They acknowledged the findings.

Training is done with new residents within 24 hours but has not been documented in the past. This was reviewed with the Plant Ops team and documentation will be provided for each resident moving forward.

This will be reviewed monthly by the Plant Ops director for accuracy.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways in the ALF's common-use areas were maintained in good repair. Findings include, but are not limited to:

The facility grounds were toured on 05/09/22, at 11:00 am. There were drop-offs of up to three inches from the pavement to the bark dust bed or grass, depending on location. The most notable areas were the side and back of the "Aspen" Building, but multiple pathways around the campus had excessive drop-offs. These created a potential tripping or fall hazard for residents.

On 05/10/22 at 11:15 am, the surveyor showed Staff 1 (Executive Director) the drop-offs, and explained the issue. Staff 1 acknowledged the findings, and stated immediate plans to rectify the problem.

On 05/11/22 the need to maintain exterior pathways in good repair was discussed with Staff 2 (Health Services Administrator), Staff 5 (Resident Services Coordinator) and Staff 6 (Director of Health Services). They acknowledged the findings.

Soil and mulch will be brought in to fill all drop-off areas in the community.

This will be maintained by Plant Ops as well as the Executive Director on weekly walk throughs.