River Grove Memory Care

Based on observations and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, and in accordance with the Food Sanitation Rules, OAR 333-150-000. include, but are not limited to:

Observation of the main kitchen and four resident houses on 09/04/24 at 10:30 am through 1:30 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:

* Interior of main kitchen oven;
* Exterior of both kitchen AC unit grates;
* Metal storage rack in dry storage;
* Kitchenette ovens in house 120 and 150 and,
* Multiple cabinets in houses with food drips, spills or crumbs.

b. The following areas were found in need of repair:

* Caulking around sides of handwashing sink in kitchen with black debris.
* Caulking in dish washing area with section of black debris.
* Caulking behind sinks in resident houses with damage, back debris build up.
* Door seals to reach in deli cooler and walk in cooler with large black substance build up.
* Reach in refrigerators in house 130 and 160 not maintaining temperatures of 41 degrees Fahrenheit (F) or lower.
* Microwaves in houses with damage to interior surfaces yielding an unsmooth uncleanable surface.
* Multiple cabinets in resident houses with damage to interior surfaces exposing porous wood surfaces.
* Thermometer in reach in refrigerator in house 120 damaged needing replaced.

c. Multiple sauté pans with damage to cooking surfaces and in need of replacement. Multiple service trays with cracked/chipped/damaged edges and/or peeling/scratched/damaged surfaces.

d. Refrigerator in house 130 noted to be at 44 degrees F at 12:05 pm and at 47 degrees F at 12:25pm. Food item temperatures stored inside we checked and found the following; milk at 49.7 degrees F and strawberry yogurt 46.5 degrees F. Care staff acknowledged they saw the fridge temperature was elevated when serving drinks to residents for lunch but had not had the chance yet to ask for permission to durn the temperature down. Staff could not remember what the temperature the fridge was at during breakfast or how long the fridge was at the elevated temperature. Staff indicated it was night shifts responsibility to monitor and record the temperature of the refrigerator. Staff turned up the cooling mechanism for the fridge at that time. Surveyor instructed staff to not serve residents food from the refrigerator and that they would let the Administrator know about the issue. House 160’s reach in refrigerator was noted to be at 49.2 degrees F at 12:35 pm. Items stored inside the fridge were checked and found the following: milk was at 47.4 degrees F and yogurt was at 48.3 degrees F. Care staff present did not know how long the fridge and food items had been at elevated temperatures. Staff voiced the refrigerator was at the coldest setting (four). Staff 1 (administrator) and staff 2 (Food Service Director) were immediately notified of the elevated temperatures and both indicated the food items would be discarded and refrigerators would be looked at by maintenance.

Surveyor toured the main kitchen and reviewed resident house concerns with Staff 2 at approximately 12:45pm and they acknowledged the identified areas. At approximately 1:30 pm the surveyor reviewed the areas in need of cleaning, repair and practices with Staff 1 (Administrator) and they acknowledged the areas in need of correction.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

(1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

This Rule is not met as evidenced by:

Based on observations and interviews, 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.

OAR 411-057-0140(2) Administration Compliance

(2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

This Rule is not met as evidenced by:

The findings of the re-licensure survey, conducted 01/03/23 through 01/05/23, 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, 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the revisit to the re-licensure survey of 01/05/23, conducted 08/21/23 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.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) who was recently admitted to the facility. Findings include, but are not limited to:Resident 3 was admitted to the facility in 11/2022. Review of the resident's records indicated the move-in evaluation lacked the following required elements:*Spiritual and cultural preferences and traditions;*Effective non drug interventions, related to mental health issues;*Personality: including how the person copes with change or challenging situations;*History of dehydration or unexplained weight loss or gain;*Recent losses; *Unsuccessful prior placements; and*Environmental factors that impact the resident's behavior, including noise, lighting and room temperature.On 01/05/23 the need to ensure move-in evaluations addressed all required elements was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator). They acknowledged the findings. No further information was provided.

2. Resident 2 was admitted to the facility in 08/2021 with diagnoses including Alzheimer's disease.Resident 2 experienced a fall on 11/20/22, which resulted in a right tibia/fibula fracture that required surgical repair. There was no documented evidence of weekly progress noted until the surgical wound resolved.The need to monitor all short-term changes of condition with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/05/23 at 10:15 am. Staff 2 reported on 01/05/23 at 11:00 am that she was unable to locate weekly progress noted for the surgical wound until it was resolved and acknowledged the findings.
Based on interview and record review, it was determined the facility failed to determine and document resident-specific interventions needed following a change of condition, or monitor conditions at least weekly, through resolution for 3 of 5 sampled residents (#s 2, 4 and 5) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care community in 01/2019 with diagnoses including vascular dementia, diabetes (type 2) and congestive heart failure.The resident's service plan, dated 10/26/22, progress notes, dated 10/01/22 through 01/03/23, temporary service plans, and RN assessments were reviewed. An RN assessment completed on 11/17/22, and weight records from 06/01/22 through 01/04/23 documented the following:06/2022: 190.5 pounds;07/2022: no weight documented; 08/2022: no weight documented;09/2022: 165 pounds;10/2022: no weight documented;11/2022: 153 pounds;12/2022: 154 pounds; and01/04/23: 152 pounds.From 06/2022 through 12/2022 the resident lost 36.5 pounds or 19.2 % of his/her body weight. This represented a severe weight loss in six months, and constituted a significant change of condition.There was an RN assessment completed on 11/17/22. However, there was no documented evidence resident-specific interventions were developed to address the weight loss.In an interview on 01/04/23 Staff 16 (CG) stated there were no interventions in place or instructions for staff, related to the resident's weight loss.Resident 5 was observed during the survey to eat 100% of three meals.There was no documented evidence interventions were developed and implemented, regarding the weight loss.On 01/05/23 the need to implement resident-specific interventions following changes of condition was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator). They acknowledged the resident had experienced severe weight loss. No further information was provided.
3. Resident 4 was admitted to the facility in 09/2020 with diagnoses including Alzheimer's dementia and anxiety disorder.A progress note dated 10/24/22 stated, "Resident has a scratch on left side of [his/her] bottom lip and bruising on left hand/wrist, purple grayish in color."There was no documented evidence of weekly progress noted until the change of condition was resolved.The need to monitor all short-term changes of condition with weekly progress noted until the condition resolved was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator). During an interview on 01/05/23, Staff 1 and Staff 2 acknowledged there was no documentation of weekly progress for Resident 4's scratch on lip and hand/wrist bruising.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. During the survey, residents in buildings 120 and 130 were observed entering the kitchens in their respective buildings and opening the refrigerator, obtaining food, making coffee, and touching multiple surfaces.The need to ensure universal precautions for infection control were exercised, including not allowing residents in the kitchen where food was prepared, was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/05/23. They acknowledged that allowing residents in the kitchen would contribute to an unsanitary environment and transmission of communicable diseases.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were carried out as prescribed for 2 of 5 sampled residents (#s 1 and 6) whose MARS and physician orders were reviewed. Findings include, but are not limited to:1. Resident 6 was admitted to the facility in 01/2021 with diagnoses including diabetes and received multiple insulin injections daily by facility staff.Resident 6's 12/01/22 through 12/31/22 MARs and signed physicians orders were reviewed and the following was identified: a. Humalog insulin (for diabetes) was ordered to be administered three times a day at meal times, with the administration and dose to be determined on a sliding scale based on the resident's CBG (blood glucose level) as follows: 151-199 = 2 units;200-249 = 3 units;250-299 = 4 units;300-349 = 5 units; andover 350 = 7 units.* On 12/06/22 at 12:00 pm Resident 6's CBG was 195. Six units of insulin were administered. According to the physicians orders, two units should have been given;* On 12/16/22 at 12:00 pm the resident's CBG was 213. Two units of insulin were administered. According to the physicians orders, three units should have been given; and* On 12/19/22 at 05:00 pm the resident's CBG was 300. Four units of insulin were administered. According to the physicians orders, five units should have been given. b. Twelve units of Lantus insulin (for diabetes) was ordered to be administered every evening and included "Do Not Hold" orders. On 12/21/22 and 12/28/22 there was no documented evidence the insulin was administered. Following physician orders as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/05/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 04/2018 with a diagnosis of dementia. Review of the resident's current physician orders and 12/01/22 through 12/31/22 MAR revealed the resident had an order for citalopram (for depression). The medication was not administered on 12/29/22, 12/30/22, and 12/31/22.The need to ensure physician orders were carried out as prescribed was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure the MAR included resident-specific instructions/parameters for the administration of PRN medications for 2 of 5 sampled residents (#s 1 and 2 ) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 08/2021 with diagnoses including Alzheimer's dementia.Review of the resident's 12/01/22 through 12/31/22 MAR revealed the resident had multiple PRN bowel care and pain medications. These PRN medications lacked clear direction to staff regarding the timing and sequence for administration of the multiple pain medications and specific instructions as to when to notify the RN/LPN for additional instructions related to administration of the multiple bowel care medications. The need to ensure there were clear instructions/parameters for staff when administering multiple PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/05/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 04/2018 with a diagnosis of dementia. Review of the resident's current physician orders and 12/01/22 through 12/31/22 MAR revealed the following:Milk of Magnesia and docusate sodium (for constipation) were both ordered to be administered PRN to the resident after three days without a bowel movement. The MAR lacked instruction to staff which medication to administer first. The resident had orders for acetaminophen, tramadol and morphine to be administered PRN for pain. The MAR instructed staff to administer tramadol when pain was not relieved by acetaminophen. There were no instructions to staff listed related to administration of the morphine. The need to ensure the MAR was accurate and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/04/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternating months from fire drills and did not address all of the required elements on the fire drill records. Findings include, but are not limited to:Review of Fire and Life Safety records for the previous six months were reviewed on 01/04/23 and identified the following:a. There was no documented evidence fire and life safety instruction was provided to staff on alternate months from fire drills.b. Fire drill records did not address the following required elements:* The escape route used; * Problems encountered and comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; and* Number of occupants evacuated. Additionally, fire drill records indicated residents had not been evacuated during the drills.During an interview with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/04/23, they reported residents had not been evacuated during fire drills. Staff 1 indicated fire and life safety training had been provided to staff, but she was unable to locate the documentation. They acknowledged the need to evacuate residents during drills and to maintain documentation of fire and life safety training provided to staff on alternate months at that time.

Based on interview and record review, it was determined the facility failed to ensure residents who can follow instructions received instruction at admission and re-instruction in fire and life safety training, at least annually after admission. Findings include, but are not limited to:Fire and life safety records were reviewed on 01/04/23. There was no documentation that residents who were able to follow instructions were provided with fire and life safety training at admission, or fire and life safety training at least annually following admission.The need to ensure residents who could understand instructions received fire and life safety instructions at admission, and annual re-instruction was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/04/23. They acknowledged the findings.

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 420 and C 422.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff demonstrated competency in all required areas within 30 days of hire, and 2 of 3 long-term staff completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 01/04/23. The following was identified:1a. There was no documented evidence Staff 11 (CG) and Staff 21 (CG), hired 07/25/22 and 11/28/22, respectively, demonstrated competency in the following areas within 30 days of hire:* Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions which require assessment, treatment, observation, and reporting.b. There was no documented evidence Staff 17 (MA), hired 10/17/22, demonstrated competency for medication administration within 30 days of hire.Staff training records were reviewed on 01/04/23. 2. Staff 11 (CG) was hired 07/25/22; Staff 21 (CG) was hired 11/28/22; and Staff 17 was hired 10/17/22. The following deficiencies were identified:a. There was no documented evidence Staff 11 and Staff 21 demonstrated competency in the following areas within 30 days of hire: * Providing assistance with ADLs;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition; and* Conditions which require assessment, treatment, observation, and reporting.b. There was no documented evidence Staff 17 demonstrated competency for medication administration within 30 days of hire.Documentation of demonstrated competency for medication administration was completed for Staff 17 on 01/04/23.The need to ensure all new hires demonstrated competency in all required areas within 30 days of hire was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/04/23 and 01/05/23. They acknowledged the findings.3. There was no documented evidence Staff 5 (MA), hired 10/28/19, or Staff 7 (MA), hired 04/03/20, completed annual in-service training in 2021 through 2022. The need to ensure staff completed a total of 16 hours of annual in-service training was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/04/23 and 01/05/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C 252, C 270, C 295, C 303 and C 310.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in residents' service plans for 2 of 5 sampled residents (#s 2 and 6) whose service plans were reviewed. Findings include, but are not limited to:Resident 2 and 6's current service plans were reviewed during survey. Each of the service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs.The need to develop individualized service plans addressing residents' nutrition and hydration preferences and needs was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator) on 01/05/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 4 sampled residents (#s 1, 2, 4 and 5) whose records were reviewed. Findings include, but are not limited to:Review of current service plans, evaluations and assessments for Residents 1, 2, 4 and 5 revealed the records offered some information relating to the residents' past and current interests. However, the facility had not fully evaluated the residents in the following areas:* 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. There was no documented evidence individualized activity plans were developed for each resident, based on their activity evaluations. On 01/05/23 the need to complete an activity evaluation and develop an individualized activity plan for each resident was discussed with Staff 1 (Administrator) and Staff 2 (Corporate Administrator). They acknowledged the findings.