Edgewood Point Memory Care

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

Based on observation, interview, and record review it was determined the facility failed to ensure an outdoor recreational area was accessible for all residents and failed to ensure all exterior pathways and accesses to the facility's common use areas were maintained in good repair. Findings include, but are not limited to: Observations of the secured courtyard on 10/15/24 and 10/16/24 showed the following: Wood edging along pathway was rotted, damaged and missing in multiple areas. These areas created a potential tripping/fall hazard for residents. A cement patio used by residents had two raised circular metal anchored plates, which created an uneven walking surface. Access to the secured courtyard was not accessible to all residents, as the two doors that exited out to the courtyard required a code to unlock the doors. In addition, the weather stripping between the doors and along the perimeter was not sealed and peeling off, causing large gaps and openings where insects, debris, and other containments could enter the building. The need to ensure residents had access to an outdoor recreation area and all exterior pathways and accesses to the facility’s common use areas were maintained in good repair was discussed with Staff 1 (MCC Director) and Staff 4 (Maintenance Director) on 10/17/24. They acknowledged the findings.

The community has hired a vendor to install 15ft sections of handrails to replace the wood edging along the pathway. The handrails will create a safer walking path for our resdients. landscaping is also scheduled to fill in any gaps around the handrails eliminating any drop offs. Moving forward the MCC and the MD will monitor the courtyard walkway edges monthly to insure that there are no gaps and that the handrails are secure for residents to use when using the walkway in the courtyard. This will also be discussed during our monthly CQI meetings for the next 3 months. The MD is also going to remove the circular metal anchored plates and fill the holes creating an even walking surface for our resdients and iliminating any fall hazards. The walking path itself will be monitored weekly by the MCC and MD to insure that the walking path is even and free from any tripping hazards. The exterior double doors will be replaced as a complete unit. New doors will be installed replacing the current exterior door frame with two new double doors, new threshold and new weather stripping. The MD will monitor the doors on a weekly basis insuring that the resdients can safely go in and out without any safety concerns or limitations. The MD will also monitor for any gaps or issues with the weather stripping making sure that there isnt any room for debris or critters from the outside to get into the building. This will also be monitored by the MD on a weekly basis.

OAR 411-054-0200 (3) General Building Exterior (3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

Based on observation and interview, it was determined the facility failed to have the setting that was physically accessible to an individual. Findings include, but are not limited to: During a tour of the MCC environment on 10/15/24 and 10/16/24 the following was identified: There were two doors that exited out to a secure courtyard that required a code to unlock the doors. The doors were misaligned which caused difficulty with opening and closing the doors properly. This created a situation which limited resident's ability to freely access the recreation area. The need to have the setting physically accessible to residents was discussed with Staff 1 (MCC Director) and Staff 4 (Maintenance Director) on 10/17/24. They acknowledged the findings. Refer to C 510.

We have added a timer to the magnetic locks that will automatically unlock the courtyard doors between 8am and 7pm, but can be changed at any time. This will allow our resdients to freely go in and out of the doors without staff assistance, during daytime hours. This will also allow the door to be fully closed. During the later evening hours a staff member will be available to unlock the doors for the residents if they wish to exit to the courtyard. This will be completed and monitored weekly by the MCC and MD.

OAR411-004-0020(2)(b) Physical Setting: Individual Accessible (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (b) The setting is physically accessible to an individual.

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.

Based on observation 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 510

Please refer to tag C0510 for POC.

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.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 03/30/2023.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on observation, interview and record review, it was determined the facility failed to ensure food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation, and food service on 07/28/22 revealed: * Splatters, spills, debris, and drips noted on: - Hand washing sink and towel dispenser; - Surfaces and underneath storage shelves, cabinets, and drawers throughout the kitchen; - Food packages on open lower shelves; - Can opener blade and casing; - Wire rack storage shelves throughout the kitchen; - Walls throughout the kitchen; - Floors and drains; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - Behind and underneath appliances; - Food storage and delivery carts; - The surface and underneath the tray line steam table; - Cage of fan blowing in food preparation area; - Vent grate blowing from ceiling; - Interior of the microwave; - The stand mixer; - A timer on a food preparation counter; and - The interior of the refrigerator in the Memory Care Unit. * Food was stored on the floor of the freezer; * Scoops were left in bins of food; * Dish racks were stored directly on the floor; * Undated and unlabeled food items were noted in the refrigerator; * The wiping cloth sanitizer bucket was not monitored to ensure the sanitizer was dispensing at the correct parts per million, staff were not aware of where to locate the test strips; * Staff were observed to not change gloves between tasks or sanitize hands upon entering the kitchen;   * Caregiving staff entering the kitchen did not have hair restrained; and * Caregiving staff assisting with meal service and delivery were not using aprons. The kitchen was reviewed with Staff 1 (Administrator). She acknowledged the findings.

Number 1: Deep cleaning of the assisted living and memory care kitchen's are scheduled to be completed on August 17th by a professional vendor, VM Group Commercial and Residential. All areas of food storage, meal preparation and serving will be cleaned with great detail. Splatters, spills, debris and drips will be removed from all surfaces.  In order to maintain compliance with Sanitations Rules and assure that this system is corrected, please see frequency of cleaning scheudle below for those areas listed in the survey.  Additional cleaning will also be included as indicated on policy and procedures.  Please see attachements (A-1 - K-4) Number 2: Implementing cleaning schedules.  See below. Cleaning schedule, AFTER EACH USE: - can opener blade and casing -behind and underneath appliances - surface and underneth the tray line steam table - stand mixer Cleaning schedule, DAILY: - hand washing sink and towel dispenser - kitchen floors- sweep and mop - clean surface of dishwashing equipment and surface area -  interior of the microwave - timer on the food preparation counter Cleaning schedule, WEEKLY: - kitchen floor drains - surfaces and underneath storage shelves, cabinets and drawers throughout kitchen - both sides and the interior of the range, grill and oven - Food storage and delivery carts Cleaning scheudle, MONTHLY: - walls throughout kitchen - Vent grates blowing the ceiling - cleaning of wire rack shelving Other areas with corrections mentioned in the survey report: - Food on lower shelves moved to closed bins. - Scoops removed from bins and placed in individual holding containers -All food in refrigerator and freezer placed on shelving in appropriate placement. -All dish racks moved to shelving units.   -All food items are labeled and dated.    - Dietary team has been inserviced on the proper use of test strips for the sanitizing solultion. Test strips will be used to ensure the sanitizer is dispensing at the correct parts per million. Staff are aware of the location of the test strips and the log to document their findings. Monitoring will occur with each meal- breakfast, lunch and dinner. - Staff have been inserviced on proper hand hygiene and glove usage. Hand sanitizer dispensers have been placed at both enteries of the assisting living kitchen and at the memory care kitchen. All employees will sanitize their hands prior to entering either kitchen. - Gloves will be worn whenever touching or preparing food.  Hand hygiene will be performed and gloves will be changed between tasks. - Hair nets have been purchaced and placed at the entry of each kitchen.  Staff have been inserviced and instructed to assure that their hair is restrained whenever entering or working in the kitchen. - Caregiving staff will wear dedicated aprons whenever assisting with meal service and delivery. - Fan has been removed from the kitchen.  Kitchen is cooled with central air conditioning - Temperature and monitoring logs are now in place for refrigerators, deli cooler, freezer and dishwasher. All staff have been inserviced on the above. We will continue to train and audit these expectations. Supplies (food storage bins, scoop bins, labels, hair nets, hand sanitation dispensers, aprons) have been purchased to assure that the above plan can be carried out now and consistently moving forward. Number 3 and Number 4 combined:   - An audit will be completed daily by the Food Service Director, Lead Chef or Administrator to assure compliance of the above plan.  Daily audit will occur for 30 days. - After 30 days, audit will be changed to weekly and will be performed by the Food Service Director or the  Administrator. - Weekly audits will be maintained on site.

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 240.

Refer to C240

The findings of the kitchen inspection, conducted 07/28/22, 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 revisit to the kitchen inspection of 07/28/22, conducted on 11/03/22, 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.