Print Inspection: HJIG

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, 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

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 initial survey of 05/11/22, conducted 09/28/22 through 09/29/22, 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.

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

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 second re-visit to the re-licensure survey of 05/11/22, conducted on 12/15/22, 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 004 Home and Community Based Services Regulations.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

1. During a tour of the memory care secured courtyard on 05/09/22, two approximately 12 foot x 4 foot wooden garden beds were observed to have disintegrating, splintered wood with multiple rusty nails protruding. These findings were reviewed with Staff 3 (MCC Administrator) on 05/09/22 at 3:00 p.m. The facility was instructed that residents should be supervised in the courtyard until the environment did not pose a threat to their safety. Review of the environment at 5:00 p.m. on 05/09/22 revealed the doors to the courtyard were locked. Prior to survey exit on 05/09/22, Staff 1 (ED) provided a written statement indicating residents would be supervised until the garden beds were removed. The garden beds were removed on 05/10/22.

The need to ensure reasonable precautions were exercised against any condition that could threaten the health, safety, or welfare of residents was discussed with Staff 1, Staff 2 (Administrator), Staff 3, Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/011/22. They acknowledged the findings.

2. On 05/09/22 at 11:10 a.m., during a facility tour, the following was observed in Building G:

* Cleaning chemicals were stored in an unlocked cupboard below a sink in the kitchenette;

* A plastic bottle that contained a cleaning chemical was sitting on top of a cart in the kitchenette; and

* The kitchenette was unsecured, next to a common area where residents were moving about freely, which posed a risk of harm to the residents.

A staff member immediately secured the unlocked chemicals at the request of the surveyor.

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

Our memory care unit is in the process of a remodel that began in April. This remodel includes the common areas of both memory care houses with carpet and paint, complete reconstruction of the kitchens, courtyard maintenance, hopper room clean and repair, doors securing the kitchen from residents and locked cabinets for chemicals.

Raised garden beds in the courtyard were removed on 5/10 prior to surveyors leaving, and the courtyard will have landscaping done.

Chemicals were removed immediately and are being stored in a locked area until new cabinets are completed.

Memory care administrator and plant ops will be monitoring the areas to make sure that they remain clear and that chemicals remain in a locked area.

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 a.m. and 10:45 a.m., the kitchen was 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:

* 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.

2. The following areas were identified as needing repairs:

* 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.

3.  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.

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 (ED) on 05/09/22  at 11:20 a.m. He acknowledged the findings.

1. A cleaning team is being 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, gauges filled and restained or painted or laminate added around the wood.

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 observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current status and care needs and provided clear direction to staff for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's Disease.

Review of the resident's 2/10/22 service plan, 02/11/22 through 05/09/22 temporary service plans, observation of the resident, and interviews with staff revealed the service plan was not reflective of the resident's care needs and did not provide clear instruction to staff in the following areas:

* Presence of dentures;

* Ability to use call system;

* Air mattress on bed;

* Customary routines related to sleeping and eating;

* Wheelchair mobility; and

* Use of foam boots.

The need to ensure service plans were reflective of the residents' current status and care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (MCC Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/011/22. They acknowledged the findings.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease.

A review of the resident's current service plan, dated 03/17/21, observations of the resident, and interviews with staff revealed the service plan was not reflective of the resident's current status and needs in the following areas:

*Ability to understand verbal cues and direction and to clearly communicate his/her needs; and

*Ability to independently use eyeglasses and dentures.

The need for service plans to be reflective of the residents' current status and care needs, as well as provide clear direction to staff regarding the delivery of services, was discussed with Staff 2 (Administrator), Staff 3 (MCC Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services). They acknowledged the findings.

Memory care administrator to spend the next few weeks evaluating all resident care plans and adding clarifying details regarding their current status and care needs. She will also be responsible for making sure that this information continues to be added to every care plan.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of the residents' current status and care needs, provided clear direction to staff, were updated quarterly and after significant changes of condition for 1 of 2 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 11/2020 with diagnoses including dementia with behavioral disturbance.

Review of Resident 5's clinical record, which included the current service plan dated 05/22/22, 08/18/22 through 09/27/22 temporary service plans, and observations of the resident identified the following:

a. The service plan was not updated quarterly as required, and was not updated following a significant changes of condition on 08/26/22 for weight loss and 09/08/22 for hospice admit.

b. The service plan was not reflective of the resident's care needs and did not provide clear instruction to staff in the following areas:

* Behaviors and interventions;

* Weight loss, weight monitoring and interventions;

* Hospice;

* Activities;

* Fall risk and current interventions;

* Use of PRN psychotropic medications and interventions;

* Escort to meals;

* Toileting and incontinence care;

* Customary routines related to sleeping and eating; and

* Wheelchair mobility.

The need to ensure service plans were updated quarterly, after significant changes of condition, were reflective of the resident's current status and care needs, and provided clear direction to staff was discussed with Staff 4 (Memory Care Coordinator) and Staff 5 (RN/Director of Health Services) on 09/29/22. They acknowledged the findings.

Memory Care Administrator and Memory Care Coordinator to spend the next few weeks evaluating all resident care plans and adding clarifying details regarding their current status and care needs. They will also be responsible for making sure that this information continues to be added to every care plan. Memory Care Administrator to review and sign all quarterly service plans, as well as significant changes of condition. Memory Care Administrator to meet with MCC weekly to discuss status of current service plans due and ensure completion on time.

RN was directed on why a new significant change must be completed with a hospice admit and did so immediately on 9/29/22. She will be sure to do this going forward.  

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, monitored, and reviewed for effectiveness, and the condition was monitored to resolution at least weekly for 2 of 2 sampled residents (#s 3 and 4) who experienced changes of condition. Resident 3 experienced repeated falls, including falls with injury.  Findings include, but are not limited to:

1. Resident 3 was admitted to the facility in 08/2017 with diagnoses including Alzheimer's disease.

Interviews with staff, observations of the resident, and review of the resident's 02/10/22 service plan, 02/11/22 through 05/09/22 temporary service plans, progress notes, and incident investigations were reviewed.

Fall prevention interventions listed on the 02/10/22 service plan included assisting the resident to the bathroom as scheduled to prevent him/her from attempting to go to the bathroom unassisted and ensuring a fall mat was placed beside the bed.

a. Resident 3 experienced the following unwitnessed 11 falls between 2/11/21 and 05/09/22:

* 03/11/22  Non-injury fall from bed;

* 03/19/22  Fall from bed with "tic tac size" abrasion on the back of his/her head;

* 03/23/22  Three falls from bed, one with bruising to his/her right elbow;

* 04/04/22  Non-injury fall from bed;

* 04/07/22  Non-injury fall from bed;

* 04/26/22  Fall from bed with bruise to left lower leg;

* 05/02/22  Non-injury fall from bed twice; and

* 05/05/22  Fall from bed with skin tear to the right elbow.

Care plan updates subsequent to each fall instructed staff to "remind resident to use call pendant."

During interviews with Staff 1 (Administrator) on 05/10/22, she stated that the resident does not have a call pendant as s/he was evaluated and determined not to be able to use it.  Staff 12 (CG) confirmed this during an interview on 05/10/22 and stated that staff check on the resident every hour due to her fall history.

The resident was observed sleeping in his/her bed multiple times on 05/09/22 and 05/10/22 with a fall mat placed beside it.

During an interview with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (MCC Administrator), Staff 4 (Memory Care Coordinator) and Staff 5 (RN/Director of Health Services) on 05/11/22, Staff 3 stated that she believed the resident had been experiencing "terminal agitation."

There was no documented evidence the facility monitored the existing fall prevention interventions at the time of each fall or for patterns related to the falls, determined and documented what new interventions were needed for the resident subsequent to each fall. The resident continued to fall and sustained multiple injuries.

b. Resident 3 was identified during the acuity interview as having a pressure ulcer on his/her sacrum.

Review of the resident's 02/11/22 through 05/09/22 facility record revealed the facility failed to monitor the pressure ulcer at least weekly through resolution.

The need to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed, implemented, and reviewed for effectiveness, and the condition was monitored at least weekly to resolution was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (MCC administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/11/22.  No further documentation was provided.

2. Resident 4 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease.

A review of the resident's current service plan, progress notes dated 02/10/22 through 04/29/22, Care Plan Updates dated 03/01/22 through 05/06/22, and incident reports and investigations dated 02/11/22 through 05/06/22, observations of the resident, and staff interviews revealed the following:

Resident 4 experienced seven falls between 02/11/22 and 04/06/22. S/he sustained bruises from the 02/11/22 fall.

There was no documented evidence new interventions or actions were determined after each fall, communicated to staff and implemented, or monitored for effectiveness.

The need to develop actions or interventions, communicate interventions with staff, and monitor interventions for effectiveness was discussed with Staff 2 (Administrator), Staff 3 (MCC Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/11/22. They acknowledged the findings.

1a. Interventions for ISP's are placed on a pre-generated form with certain interventions then additional interventions are added to each form that are specific to the resident's need. "Remind resident to use call pendant" is one of the pre-generated terms.

Pre-generated forms to all be remade with more details including whether using a call pendant is applicable for that resident.

Interventions were working to help with injury as several of the falls were non-injury due to the interventions in place. Moving forward, med techs, nurses and MCC to do more documentation of monitoring of the interventions in place and if they are working to prevent injury.

1b. RN missed 2 weeks of monitoring resident's short-term change of condition but resident was on hospice, who was monitoring on those weeks.

RN to make sure that adequate documentation in resident's chart of who monitored each week and how it's progressing.

2. Med techs, nurses and MCC to do more documentation of monitoring of the interventions in place and if they are working to prevent injury.

All of these steps will be monitored by the Health Services Administrator to ensure it is being completed and documented properly.

Based on interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition had resident-specific instructions and interventions developed and monitored for effectiveness for 1 of 2 sampled residents (#5) who were reviewed for changes in condition. This is a repeat citation. Findings include, but are not limited to:

Resident 5 was admitted to the facility in 11/2020 with diagnoses including dementia with behavioral disturbance.

The resident's 05/22/22 service plan, 08/18/22 through 09/27/22 care plan updates, progress notes, and incident investigations were reviewed during the survey.

a. Review of the current service plan dated 05/22/22 noted the following:

* Fall intervention - safety checks every two hours during night shift;

* Inability to use call system; and

* Inability to recall information after five minutes.

b. Resident 5 experienced five falls between 09/23/22 and 09/27/22.

Care plan updates subsequent to each fall instructed staff to remind the resident to use call pendant, remind the resident to use assistive devices, and keep the room free of clutter.

Staff 5 (RN) had evaluated the falls and was in coordination with hospice care team on 09/26/22 and 09/28/22.

There was no documented evidence the service planned fall interventions were resident specific, reviewed for effectiveness, or new interventions developed after each subsequent fall.

On 09/29/22 Staff 5 acknowledged the lack of resident specific fall interventions and reported she would write a temporary care plan that included resident specific fall interventions for staff to follow.

The need to ensure interventions were resident specific, monitored and reviewed for effectiveness was discussed with Staff 4 (Memory Care Coordinator) and Staff 5 on 09/29/22. They acknowledged the findings.

a. Interventions for ISP's are placed on a pre-generated form with certain interventions then additional interventions are added to each form that are specific to the resident's need. "Remind resident to use call pendant" is one of the pre-generated .

Pre-generated forms to all be remade with more details including whether using a call pendant is applicable for that resident.

Moving forward MCC to ensure more documentation of monitoring the interventions in place and if they are working to prevent injury. MCC to ensure ISP's are in compliance on an ongoing basis.

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation. Findings include, but are not limited to:

There was no documented evidence the facility was using an ABST that would determine a staffing plan reflective to meet the 24-hour scheduled and unscheduled needs of residents and included all the required ABST elements.

On 09/28/22, the need to ensure the facility implemented an ABST was reviewed with Staff 3 (MCC Administrator) and Staff 4 (Memory Care Coordinator). They acknowledged the findings.

Memory Care Administrator to communicate with Home Office about needing ABST. Home Office to outline directions for doing this with current program of Point Click Care.

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 (ED), Staff 2 (Administrator), and Staff 6 (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 annually.

The need to have documented evidence of all fire and life safety training components was discussed with Staff 1 (ED), Staff 2 (Administrator), and Staff 5 (Plant Operations Director) on 05/10/22 and 05/11/22. They acknowledged the findings.

Training is done with new residents within 24 hours for residents that are mentally capable of following instruction. This does not apply to our memory care residents as none of them have the mental capacity to retain the training for more than a few minutes.

MCC and nurse to determine during assessment if resident is able to obtain this information and will document in the care plan when the resident is incapable of following such instruction.  

Based on observation, 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 C260, C270, C510, C513, and Z164.

Memory Care Administrator to review plan of correction weekly and request updates from MCC, Plant Ops, ED and Lead Housekeeper. Will faciliate completion of projects as needed.

Based on observation and interview, it was determined the facility failed to ensure the secured memory care courtyard was kept orderly and exterior pathways were maintained in good repair. Findings include, but are not limited to:

The interior courtyard of the MCC was toured on 05/09/22. There were drop-offs of up to approximately 4 inches from the concrete surface to the planting beds in multiple areas.  This represented a fall risk for residents.

Tomato cages, garden hoses, and a sprinkler head were noted to be on the ground by the garden beds.

The memory care environment was toured with Staff 3 (MCC Administrator) on 05/09/22. The need to ensure the secure memory care courtyard was kept orderly and exterior pathways maintained in good repair was also discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/11/22. They acknowledged the findings.

Soil and mulch is being 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.

Any tomato cages, hoses and sprinklers were removed prior to survey exit.

Based on observation and interview, it was determined the facility failed to ensure the secured memory care courtyard was kept orderly and exterior pathways were maintained in good repair. This is a repeat citation. Findings include, but are not limited to:

The interior courtyard of the MCC, located between Fir and Grove Cottage was toured on 09/28/22 at 10:30 am. The following was identified:

* Multiple areas of drop offs in the interior MCC courtyard that were upwards of 2 1/2 inches in depth from the sidewalk to the planting bed;

* Debris and refuse throughout the courtyard (paper, a white towel, a broken lantern, plastic and various other debris scattered throughout the courtyard;

* Buildup of cobwebs in the eaves and fascia where residents sat outdoors;

* Fire sprinkler room off the courtyard was unlocked and had an unlabeled chemical spray bottle on the floor and walls without sheetrock that exposed insulation;

* A utilities shed that housed various electrical wires had exposed nails in the top and was not secured;

* Siding near the fire sprinkler room was not secured to the exterior of the building; and

* A recessed lighting fixture was falling down from the patio roof.

The need to ensure the secure memory care courtyard was kept orderly and exterior pathways maintained in good repair was discussed with Staff 4 (Memory Care Coordinator), Staff 6 (Plant Operations) on 09/28/22. They acknowledged the findings.

Memory Care Coordinator will be doing weekly checks to make sure that areas are being properly maintained and will report any issues to Plant Ops Director or Housekeeping Lead, as needed.

Soil and mulch is being 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.

Plant Ops Director and Housekeeping Lead made aware of issues to be resolved 10/3/22. Immediate safety hazards were taken care of 9/28/22.

Community recently had fire sprinkler/fire alarm testing which could have been cause of fire sprinkler room being unlocked. Plant Ops Director to ensure this is closed and locked after each testing.

Additonally, roof was being repaired during site visit, which could be cause of some of the debris. MCC to check at end of each day for debris, until roof project is complete.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. Findings include, but are not limited to:

During a tour of the environment on 05/09/22, the following areas were observed to be in need of cleaning or repair:

1. Cottage G

* There was a build-up of brown/black/gray matter and debris, purple disinfectant, and multiple nails and staples on the floor of the housekeeping room; a build-up of brown/black/pink matter in the utility and counter sinks; and brown matter inside and on the base of the hopper.

* There was a build-up on brown/black/gray matter and debris on the floor of the laundry room, an approximately 4" by 8" rip in the linoleum between the washer machines, and  holes in the wall by the detergent.

* There were multiple scrapes in the paint and wood in the kitchenette, on resident room door frames, and corners of the hallway.  

* Two circular plumbing cleanouts, approximately 8 inches in diameter, located on the floor by  Rooms 2 and 7, were depressed and had fraying carpet around them, creating a tripping hazard.  

2. Cottage F

* There were multiple scrapes in the paint and wood on  resident room door frames and corners of the hallway.

* The housekeeping room had a hopper that was not operational, had a dense build-up of brown matter inside the bowl, and had broken cabinet doors lying on top of it. There was a build-up of brown/black/gray matter and debris on the floor.

* A resident transfer device, fall mat, bedroll, and shelving unit were stored in the hallway by room 5.

The areas in need of cleaning and repair were reviewed with Staff 3 (MCC Administrator) during a tour of the environment on 05/09/22. The need to ensure the environment was maintained clean and in good repair was also discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/11/22. They acknowledged the findings.

Our memory care unit is in the process of a remodel that began in April. This remodel includes the common areas of both memory care houses with carpet and paint, complete reconstruction of the kitchens, courtyard maintenance, hopper room clean and repair, doors securing the kitchen from residents and locked cabinets for chemicals. This will not be fully completed until August 2022.

Raised garden beds in the courtyard were removed on 5/10 prior to surveyors leaving, and the courtyard will have landscaping done.

Anything that was in the hallway was removed and placed in storage areas.

Memory care administrator will be doing weekly checks to make sure that areas are being properly maintained.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained clean and in good repair. This is a repeat citation. Findings include, but are not limited to:

During a tour of the environment on 09/28/22, the following areas were observed to be in need of cleaning or repair:

Grove Cottage:

* Multiple broken cabinets and cabinet doors off their hinges laying around the laundry rooms;

* Brown, black, pink buildup in the hopper sink;

* Buildup gray matter and debris in the utility sink and countertop sink in the laundry room; and

* Approximately 12 feet of wall was missing behind washer and dryers which exposed insulation, plumbing and wires.  

Fir Cottage:

* Hopper sink in the laundry had a buildup of gray matter inside the bowl; and

* Multiple door frames had scrapes in the paint (Rooms 1, 5, 6, 7, 8, 9,10 and an exit door).

The need to ensure the environment was maintained clean and in good repair was discussed with Staff 4 (Memory Care Coordinator) and Staff 6 (Plant Operations) on 09/28/22. They acknowledged the findings.

Memory Care Coordinator will be doing weekly checks to make sure that areas are being properly maintained and will report any issues to Plant Ops Director or Housekeeping Lead, as needed.

Plant Ops Director and Housekeeping Lead made aware of issues to be resolved 10/3/22.

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 160, C 240, C 420, C 422, C 510, and C 513.

Please refer to C tag corrections above.

Based on observation and interview, 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 and C 513.

Please see C tags above

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 260 and C 270.

Please refer to C tags above

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 260 and C 270.

Please see C tags above

Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluation for 2 of 2 sampled residents (#s 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:

A review of the service plan for Residents 3 and 4 and an interview with Staff 2 (Administrator) revealed the following:

1. There was no documented evidence of an activity evaluation which addressed the following required elements:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate; and

* Identification of activities for behavioral interventions.

2. There was no documented evidence individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were developed and documented.

The need to ensure the facility completed an activity evaluation addressing the required elements and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 2 (Administrator), Staff 3 (MCC Administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services) on 05/11/22. They acknowledged the findings.

MCC to meet with LE to formulate a more detailed activity plan for each resident. They will meet quarterly to confirm that the plan is still working for each resident and make any changes necessary. MCC will then make sure that all information is documented in the care plan for the resident.

Based on interview and record review, it was determined the facility failed to evaluate residents for activities and to develop individualized activity plans from the evaluation for 1 of 2 sampled residents (#5) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:

A review of the service plan for Residents 5 revealed the following:

1. There was no documented evidence of an activity evaluation which addressed the following required elements:

* Past and current interests;

* Current abilities and skills;

* Emotional and social needs and patterns;

* Physical abilities and limitations;

* Adaptations necessary for the resident to participate (use of a wheelchair); and

* Identification of activities for behavioral interventions.

2. There was no documented evidence individualized activity plans, which addressed what, when, how, and how often staff should offer and assist the resident with activities, were developed and documented.

The need to ensure the facility completed an activity evaluation addressing the required elements and developed an individualized activity plan based on the evaluation for each resident was discussed with Staff 1 (ED) and Staff 4 (Memory Care Coordinator) on 09/29/22. They acknowledged the findings.

MCC to meet with LE weekly to formulate a more detailed activity plan for each resident until completed. They will meet quarterly to confirm that the plan is still working for each resident and make any changes necessary.

Based on observation and interview, it was determined the facility failed to ensure furniture in the secure outdoor recreation area was of sufficient weight to prevent resident injury or aid in elopement. Findings include, but are not limited to:

During a tour of the environment on 05/09/22, multiple light-weight wicker chairs were noted in the secured courtyard. The courtyard was toured with Staff 3 (Administrator) on 05/09/22. She acknowledged the findings.

The need to ensure outdoor furniture in the secured outdoor recreation area was of sufficient weight to prevent resident injury or aid in elopement was discussed with Staff 1 (ED), Staff 2 (Administrator), Staff 3 (MCC administrator), Staff 4 (Memory Care Coordinator), and Staff 5 (RN/Director of Health Services). The facility acknowledged the findings. The furniture was removed prior to survey exit.

All furniture that was determined to be too lightweight was removed prior to survey exit and replaced by furniture of a more substantial weight.

2. The MCC was toured on 09/27/22. Resident rooms including 3b, 6a, and 11 in "Fir" cottage lacked any means of identifying the room for the residents that occupied these rooms.

On 09/29/22, the need to ensure the facility had a system in place for resident's to individually identify their rooms was discussed with Staff 4 (Memory Care Coordinator). She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the memory care community individually identified residents' rooms to assist residents in recognizing their rooms for 1 of 2 sampled residents (#5). Findings include, but are not limited to:

1. Observations of the MCC on 09/28/22 and 09/29/22, and review of Resident 5's current service plan identified the following:

* Resident 5 had a history of wandering prior to admission to the MCC;

* The current service plan noted the resident was not oriented to current location, was unable to recall information after five minutes, and had behaviors that included "invading others rooms"; and

* Observation of Resident 5's room showed the room was only identifiable by room number and name.

There was no documented evidence the facility individually identified Resident 5's room in an attempt to provide support with recognizing their room.

The need to to ensure the facility had a system in place for resident's to individually identify their rooms was discussed with Staff 1 (ED) and Staff 4 (Memory Care Coordinator) on 09/29/22. They acknowledged the findings.

Name plates were ordered for all residents missing them on 9/28/22. These arrived and were put into place 10/3/22.