Bridgecreek Memory Care

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at textures, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 02/07/24 from 10:30 am through 1:00 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Interiors of reach in freezers; * Vents, light fixtures, sprinklers; * Wall behind shelf of dry goods; and * Interior of ovens. b. The following areas were found in need of repair: * Wall under three-compartment sink with large hole; and * Wall in secondary dry/freezer storage with hole by electrical conduit. c. Single service utensils, straws were stored with food contact surfaces open to possible contamination. d. Sauté pan found with multiple scratches where non stick surfaces had worn, scratched off. e. Kitchen did not have a thin diameter thermometer probe as required to accurately temp thin food products. f. Raw shell eggs were stored on a middle shelf with other items underneath them posing potential for cross contamination. Carton of eggs had other RTE (ready to eat) items stored on top of the used carton, again posing potential for cross contamination. g. Staff were planing on serving ice cream to residents with thickened liquids and were unaware that was an unsafe texture for residents needing thickened liquids. Surveyor intervened and pudding was served as dessert instead. Staff were observed to puree meal items with hot water, thus diluting the flavor and nutritional value of the pureed food items. h. The facility did not have a system in place to monitor effective sanitation chemical of the dish machine. Surveyor asked for staff to check concentration of chemicals and it was reading 0 ppm. The sanitizing chemical was out and once switched to full jug was reading at 200 ppm. Kitchen staff interviewed acknowledged they were not checking the concentration of the chemicals and did not know how to do it. Staff 2 (Dietary Manager) and Staff 1 (Executive Director) reviewed above areas of concern on 02/07/24 and they acknowledged the need for corrective action.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule Food Sanitation Rules, OAR 333-150-000. C240 A - All food spills,splatters, loose food and trash debris, dirt, dust, black matter and grease will be cleaned from on or underneath the following: * Interiors of reach in freezers; * Vents, light fixtures, sprinklers; * Wall behind shelf of dry goods; and * Interior of ovens. C240 B- The following areas will be repaired: * Wall under three-compartment sink with large hole; and * Wall in secondary dry/freezer storage with hole by electrical conduit. C240 C- All unwrapped straws will be discarded and facility will use only wrapped straws. C240 D- Sauté pan that was found with multiple scratches will be disposed of. C240 E- Kitchen will purchase a thin diameter thermometer probe as required to accurately temp thin food products. C240 F-Raw shell eggs will be stored on the bottom shelf to prevent the potential for cross contamination. No RTE (ready to eat) items will be stored on top of the used cartons. C240 G- Residents with an order for thickened liquids will receive pudding for dessert in place of icecream. If puree meals need diluted, broth or cream will be used instead of water so the flavor and nutritional value are not compromised. C240 H- The facility will put a system in place and ensure staff are properly trained on how to check the concentration of chemicals in the dish machine and how to document chemical ppm to ensure the correct levels are running at all times for proper sanitation. The Dietary Manager will keep the kitchen in good repair and in a sanitary manner at all times. Staff will be given additional training on cleaning, equipment operation and documentation, sanitation and food prep for altered textures. Dietary Manager will ensure staff are completing their daily and weekly cleaning checklist. DM and ED will do a weekly walk through of the kitchen to ensure compliance. Dietary Manager and Executive Director will be responsible for ensuring these repairs/corrections are completed and monitored.

Based on observation, record review and interview, 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.

OAR 411-057-0140(2) Administration Compliance Z 142 - Refer to plan of correction for C240

The findings of the kitchen inspection, conducted 02/07/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first re-visit to the kitchen inspection survey of 02/07/24, conducted 04/25/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, during a site visit conducted on 01/02/24, it was confirmed the facility had not documented they have observed and evaluated an individual's ability to perform safe medication and treatment administration unsupervised. Findings include, but are not limited to: During swing shift on 01/02/24, CS observed Staff 5 working alone. During separate interviews on 01/02/24, Staff 2 (RN) indicated new med techs were trained for two weeks with another med tech who had been fully trained. S/he indicated that there were check ins with new staff to ensure they were comfortable with their position and if there was additional training needed. Staff also complete a 30-day competency checklist which was observed and signed off by a trainer. Staff 4 (MT) indicated Staff 5 was a new MT that would be working the swing shift passing medications alone. A review of MT training records indicated four out of six med techs to have been completed. Staff 5 competency training had been incomplete and had not been signed off by a supervisor. it was confirmed the facility had not documented they have observed and evaluated an individual's ability to perform safe medication and treatment administration unsupervised. On 01/02/24, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: ED stated that the facility would complete and sign off MT competency.

Based on observation, interview, and record review, during a site visit conducted on 10/19/23, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: In separate interviews on 10/19/23, Staff 1 (RCC) and Staff 6 (Executive Director) stated, "The facility has been short staffed on swing shift, it is an ongoing issue we are aware of and have been trying to work on. "Staff 2 (RCC) stated, "The memory care has 48 residents, with at least 10 two person transfers." Staff 6 stated, "Two kitchen staff members who used to be caregivers have been often filling in." A review of timecards and the labor distribution report for 08/05/23 indicated the facility was staffed lower than required. A review of the staff schedule for August and September 2023 indicated on 08/05/23 staff scheduled did not match timecards. The shower schedule indicated Resident 4 was to receive showers on Sundays during day shift. A review of the shower sheets indicated Resident 4 did not receive a shower until Wednesday 10/18/23. On 10/19/23, CS observed one MT four CG's, (one who was in training), and one treatment aid. CS observed Resident 4 to have recently showered, however his/ her nails were unclean with debris embedded. It was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. On 10/19/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility is aware they are short staffed on swing shift and have been continuously trying to hire. Have interviews lined up for the following week.

Based on interview and record review, conducted during a site visit on 10/19/23, it was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. Findings include, but are not limited to: In separate interviews on 10/19/23, Staff 1 (RCC) stated, "The facility has been short staffed on swing shift, it is an ongoing issue we are aware of and have been trying to work on." Staff 2 (RCC) stated, "The memory care has 48 residents, with at least 10 two person transfers." During a phone interview on 10/20/23, Staff 6 (Executive Director) stated the facility was using the ODHS ABST and acknowledged the facility had not been staffing to the hours indicated in the tool for swing shift. On 10/19/23, the facility's ABST was reviewed, and the staffing levels generated indicated the facility required six care staff on day shift, five care staff on swing shift, and two care staff on night shift. There were 30 residents' profiles that had not been updated quarterly. A review of the posted staffing plan indicated four CG's and one MT was to be scheduled, and one MT and one GC for night shift. The posted staffing plan did not match the current facility staffing. It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. On 10/19/23, the findings were reviewed with and acknowledged by Staff 1.

The findings of the on-site investigation, conducted on 10/19/2023, are documented in this report. The investigation 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. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse Notes on Abbreviations: " The abbreviations listed above can be used in the report without identifying the abbreviation within the report itself. " Residents will be identified by "Resident 1", "Resident 2" etc, do not abbreviate. " Staff will be identified by "Staff 1", "Staff 2" etc. do not abbreviate. " If you introduce an abbreviation in the report, make sure it is a word that has a standard abbreviation associated with it and that it needs to be abbreviated. You don't need to abbreviate a word that you only use once in a report.

Based on interview and record review, it was determined the facility failed to ensure short-term changes of condition were evaluated, interventions were determined and communicated with staff, and changes were monitored until resolved for 2 of 3 sampled residents (#s 2 and 3) reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 03/2021 with diagnoses including dementia and diabetic neuropathy. The resident's progress notes, dated 12/30/22 through 03/27/23, temporary service plans (TSPs), RN assessments, and incident reports and investigations were reviewed, and staff were interviewed. The following changes of condition were identified: * 12/29/22 - Left buttock pressure wound; * 01/01/23 - Non-injury fall next to bed; * 01/11/23 - Non-injury fall next to bed; * 02/06/23 - Non-injury fall in the bathroom; * 02/22/23 - Burning and pain with urination; * 02/25/23 - Non-injury fall next to bed; * 02/27/23 - Non-injury fall next to bed; and * 02/27/23 - Non-injury fall in resident's room. There was no documented evidence the falls, pressure wound and pain with urination was monitored weekly until resolution. The need to monitor changes and document progress weekly through resolution was discussed with Staff 1 (Executive Director ), Staff 2 (Regional RN), Staff 3 (Director of Health Services/RN), and Staff 4 (RCC) on 03/28/23. They acknowledged the findings. No additional information was provided. 2. Resident 3 was admitted to the memory care community in 11/2022 with diagnoses including dementia with agitation, hypertension, and diabetes. Review of the residents progress notes, dated 12/27/22 through 03/27/23, temporary service plans, and incident reports revealed the resident had experienced the following short-term changes of condition: * 01/19/23- Resident to resident altercation during activity game; * 01/29/23- Injury fall near facility salon; * 01/30/23- Non-injury fall in resident's room; * 02/05/23- Verbal altercation in dining room; * 02/05/23- Non-injury fall in resident's room; * 02/16/23- Resident to resident physical altercation in common area; * 02/23/23- Non-injury fall in resident's room; * 02/23/23- Injury fall in hallway; * 03/02/23- Non-injury fall in hallway; * 03/03/23- Non-injury fall in dining room; * 03/05/23- Non-injury fall in common room There was no documented evidence new interventions were developed for repeated incidents, clear directions were provided to staff, or existing interventions were evaluated for effectiveness. On 03/29/23, the need to identify changes of condition, develop resident-specific interventions, and  evaluate the interventions for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (Regional RN). They acknowledged the findings.

1 - Residents 2 & 3 Change of Condition were reviewed and documentation completed reflecting the changes and SP updated as needed, fall interventions and any additional behavior support montioring 2 - 24 hour process will be reviewed and retrained with staff to assure that communication from staff regarding visualized changes are being documented for further follow up. RN, ED, RCCs, will review in clincical meeting daily and address/document accordingly. Training to be conducted with facility care staff 3 - Review of 24 hour binder and audit tool will be conducted Mon-Fri during clinical meetings ED, RN, RCCs are responsible

Based on observation and interview, it was determined the facility failed to ensure the courtyard surfaces were maintained in good repair. Findings include, but are not limited to: Observation of the secured courtyard on 3/27/23 showed drop offs along the concrete patio of up to one and one-half inches in multiple areas. The drop offs create a potential tripping/fall hazard for residents. The courtyard was reviewed with Staff 1 ( Executive Director), Staff 5 (Maintenance Director), and Staff 18 (Regional Director of Operations) on 03/28/23. They acknowledged the findings.

1 - Exterior deficiencies noted in the 2567 have been reviewed and repaired. 2 - All staff to be trained on utilizing work order system to assure needed repairs are addressed timely. As well as notification when there are areas where residents could be at risk for tripping or falling. 3 - ED and Maintenance Director to conduct weekly walk throughs, as well as monthly QA meeting audits. RDO to complete quarterly visit to complete building walk. 4 - RDO, ED and Maintenance Director

Based on observation and interview, it was determined the facility failed to ensure the interior was clean, in good repair, and free from unpleasant odors. Findings include, but are not limited to: Observations of the facility on 03/27/23 and 03/28/23 showed the following: * Chipped, dinged, gouged, scratched, and scuffed walls, doors, and door frames throughout the facility, including inside resident units; * Baseboards throughout the facility had an accumulation of dirt and debris in corners and along the perimeter; * Multiple bathrooms had thick black accumulation along the baseboards and shower thresholds; * Multiple toilets had stained, missing, or black spots on the caulking around the bases of the toilet; * Multiple resident wheelchairs had torn armrests; and * There was a strong urine odor in and around Resident Room 5 that did not dissipate. The areas in need of cleaning and repair were shown to and discussed with Staff 1 ( Executive Director), Staff 5 (Maintenance Director), and Staff 18 (Regional Director of Operations) on 03/28/23. They acknowledged the findings.

1 - Complete room audit will be conducted on all resident apartments and common areas to assure they are in good repair to include but not limited to: scratches, dings, gauges, baseboards, build up, proper caulking, and odor free. Resident wheelchairs will be assessed and proper repairs completed or new wheelchairs ordered.   2 -  Administrator, maintenance and housekeeping will do a weekly walkthrough utilizing the environmental QA form.Work order binder to be brought to stand up daily to review and assure items are being addressed Administrator, DHS, and RCC will review resident wheelchairs and work on replacements and/or repairs. 3) The weekly audits will be reviewed at QA for trends and QAPI opportunities 4) ED responsible

Based on observation, interview, and record review, it was determined the facility failed to provide non-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 C510 and C513.

See POC for C510 and C513

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 C270.

See POC for C270

Based on interview and record review, it was determined the facility failed to evaluate behavioral symptoms which negatively impacted the resident or others, and include on the service plan for 1 of 3 sampled residents (#3) who exhibited challenging behaviors. Findings include, but are not limited to: Resident 3 was admitted to the memory care community in 11/2022, with diagnoses including dementia with agitation. In an interview on 03/27/23, Staff 1 (Executive Director) identified Resident 3 with a multitude of behavioral issues, including verbal and physical altercations with other residents. Review of Resident 3's progress notes, dated 12/27/22 through 03/27/23, temporary service plans, and incident reports revealed the resident was involved in the following altercations: * On 01/19/23, Resident 3 grabbed another resident during a ball toss game, and the two "exchanged blows", before staff intervened; * On 02/05/23,  a facility nurse heard a commotion in dining room and hurried to find Resident 3 in a "loud verbal argument" with several other residents; and * On 02/16/23, Resident 3 stated to Staff 9 (Activity Director) that another resident had been "beating [him/her] in the head". Resident 3's service plan, dated 12/28/22, lacked documented evidence the negatively impactful behaviors were evaluated or addressed on the service plan. On 03/29/23, the need to evaluate behaviors with negative impact, and include those behaviors on residents' service plans was discussed with Staff 1 (Executive Director) and Staff 2 (Regional RN). They acknowledged the findings.

1 - Resident 3  service plan to be updated to reflect negative behaviors and additional services requested from MD in regards to resident behavior and agitation. 2 - IRs and resident behaviors will be reviewed daily in 24 hour process clinical meeting to assure all interventions, TSPs and other needed changes to SP are addressed. 3 - Service Plans/Evals due are reviewed daily during 24 hour process . Will audit 2 service plans monthly as part of ongoing QA process ED and DHS responsible

The findings of the change of ownership survey, conducted 03/27/23 through 03/29/23, 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, 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. 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 re-visit survey to the change of owner survey of 03/29/23, conducted 07/05/23, 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 for Home and Community Based Services Regulations. The facility was found to be in substantial compliance with the regulations.

Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and to ensure meals were served at appropriate temperatures and were palatable, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observation of the kitchen on 1/27/23 at 11:45 am through 12:45 pm revealed the following deficiencies: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter and grease was visible on or underneath the following: * Kitchen entrance door threshold: * Walls throughout kitchen area; * Dirty rag stored on hand washing sink; * Reach in Refrigerator/Freezer with heavy dust build up; * Reach in refrigerator/freezer handles and exterior doors; * Kitchen refrigeration unit with dust build up; * Knife storage container; * Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers; and * Radio. b. The following areas were found in need of repair: * Kitchen entrance door with damage and missing paint in threshold and door jams; * Caulking around dish machine area with black substance buildup or missing/cracked/damaged pieces; * Piece of tile missing; * Wall by window damaged; * Molding around window missing/damaged; and * Wood shelving by window damaged. c. Ice scoop stored touching items in a bin, next to hand washing sink, open and exposed to possible contamination. d. Food processor cracked and missing pieces, multiple pots and pans with damage. e. Two of three kitchen staff did not have hair restrained as required. f. Large can opener with chemical damage that was causing rust to accumulated on blade. g. During meal service multiple kitchen staff observed to touch ready to eat foods with bare hands. Staff were unaware that they could not touch ready to eat foods with their hands. Staff 2 (Dietary Manager) indicated they did not have tongs to use. h. The facility did not have a system in place to monitor effective sanitation chemical of the dish machine. Vendor services the chemicals and checked when the chemicals were out, but staff could not remember when the vendor last service check was completed. Staff were not checking sanitizer concentration in between visits and had no idea what chemical was used. Staff 2 (Dietary Manager) and Staff 1 (Executive Director)  toured the kitchen with the Surveyor at 12:45 pm. Staff 1 and Staff 2 acknowledge the above areas of needing cleaning and repair.

1. (a)Kitchen cleanliness will be addressed and deep cleaning will be completed for all areas in kitchen to include reach in fridge/freezer, kitchen walls and doors, knife storage, vent covers, etc as outlined in SOD. 1. (b) Kitchen repairs will be completed as stated in SOD to include door frames, doors, caulking, shelving and moldings. 1. (c, d, f) Kitchen items that are in poor repair as stated in SOD will be repaired, replaced or moved 1. (e) Hair restraints will be provided and worn by kitchen staff 1. (g) Employees will be re-trained/inserviced to assure proper food sanitation/safety rules are followed to include the  use of gloves and proper serving utensils. 1. (h) Facility will contact chemical provider for proper instructions on chemical concentration and frequency, as well as inservice on chemicals and their uses 2. Rounding of facility will be completed daily to assure proper cleanliness and procedures are in place as inserviced with staff 3. Facility will evaluate defeciences weekly with maintenance walk throughs and weekly kitchen inspections 4. Executive director, Maintenance Director, Dietary Manager are responsible to assure all deficiences are corrected and maintain compliance   kitchen cleaning logs and report in management stand up meeting.

Based on observation, record review and interview, 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.

See POC for C240

The findings of the kitchen inspection, conducted 1/27/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 01/27/23, conducted 04/18/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.