Alderwood ALF

The findings of the on-site investigation, conducted 07/12/24 are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 and Division 57 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the kitchen inspection, conducted 02/21/24, 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 re-visit to the kitchen inspection of 02/21/24, conducted 06/03/24 through 06/05/24, 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 and interview, it was determined the facility failed to maintain a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen on 02/21/24 showed the following areas were in need of cleaning or repair.a. Food spills, splatters, debris, dust, white fuzzy substance, black substance, webs and/or dirt were observed on, inside, underneath and/or dangling from the following areas: * Floors throughout the kitchen and dry storage areas, under all equipment, appliances, and counters;* Floor drains; * Fire extinguisher;* Shelving units throughout the kitchen, refrigerator and freezer units;* Clean dish/pan storage shelves;* Both ovens;* Top of the water heater, walls/floors in linen storage, and walls in janitor closet;* Walls and ceiling throughout the kitchen;* Ceiling vents, stove hood and vents, and suppression spigots in front of the hood vents;* Air conditioning units and small fans;* On top of the stand mixer; and * Fans in the walk in refrigerator.b. Additional observations showed the following:* Food items stored directly on the floor and other food items on the floor underneath bread shelf and in dry storage;* Thick tape was wrapped around the hinge, holding it in place for the glass doors of the walk in refrigerator;* Spray foam along pipe in the walk-in freezer above a large ball of ice was chipped and pieces coming off;* Three cutting boards were significantly worn and had knife damage;* Stand up freezer had a large bulging section of the door along with heavy amounts of frost throughout the freezer;* Black plastic cover on the top of the stand mixer had a large crack on the right side with loose plastic;* Caulking under the spice shelf was both discolored in sections and missing in others;* Chipped, dinged cupboards and shelving throughout the kitchen;* Multiple areas of the floor that was dinged, chipped or had missing pieces. Areas of flooring underneath and around equipment edges and dips and dings to the tiles;* Two plastic/rubber scraping spatulas were dinged with chunks missing from the scraper edge. Two small frying pans with significant oxidation and discoloration as well as one large frying pan;* Three broken dish baskets were noted with missing plastic pieces, as well as significant discoloration and dark accumulation;* Broken floor tile near the toast area;* No test strips could be located;* One of two handwashing sinks did not have hot water. The water was left running approximately 3.5 to 4.5 minutes. The water remained luke warm. Staff 2 (Kitchen Manager) indicated the sink was an ongoing problem but the other ones in the kitchen had hot water without issue;* Cupboards in dining room noted with significant spills and debris in the interior;* No written policy for sick kitchen staff was in place; and* The dish machine was identified as a high temperature machine with chemical boosters by Staff 2. The temperature dial would not rise with the temperature of the machine when in use. The needle on the gauge hovered between 120 and 130 degrees throughout the wash and rinse cycles. The dish machine had no data plate.The need to ensure the kitchen was kept clean and in good repair was discussed with Staff 1 (Administrator) and Staff 2 (Kitchen Manager) on 02/21/24. Staff 1 and Staff 2 stopped use of the dish machine. Staff 2 indicated dishes would be washed and sanitized in the three compartment sink while waiting on repair of the unit. The staff acknowledged the findings.

The findings of the Change of Ownership survey conducted 06/12/23 through 06/14/23 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 and Home and Community Based Services Regulations OARs 411 Division 004.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 06/14/23, conducted 03/26/24 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 observation, interview and record review, it was determined the facility failed to ensure resident evaluations were reflective of the resident's health status, current needs or addressed all required components for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose new move-in or quarterly evaluations were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 2016 with diagnoses which included diabetes. Observations, resident and staff interviews, and review of the record was conducted during the survey.The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:* Visits to health practitioner(s), ER, hospital or NF in the past year;* History of dehydration or unexpected weight loss or gain;* Recent losses;* Unsuccessful prior placements;* Elopement risk or history;* Smoking, ability to smoke safely;* Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.On 06/14/23, the need to ensure Resident 2's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings.2. Resident 3 moved into the facility in 01/2023 and had diagnoses which included dementia. Observations, resident and staff interviews, and review of the record was conducted during the survey.The most recent evaluation, dated 05/18/23, was not reflective of the resident's health status, current needs or did not address the required components in the following areas:* Customary routines: sleeping;* Visits to health practitioner(s), ER, hospital or NF in the past year;* Mental issues including: Presence of depression, thought disorders or mood problems;* Pain: Pharmaceutical and non-pharmaceutical intervention, including how the resident expressed pain or discomfort;* Fall risk history;* Complex medication regimen;* Unsuccessful prior placements;* Elopement risk or history;* Smoking, ability to smoke safely;* Alcohol and drug use; and * Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.On 06/14/23, the need to ensure Resident 3's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the findings.
3. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema.Review of the most recent evaluation dated 06/05/23 revealed the evaluation was not reflective of the resident's health status, current needs, or did not address the required components in the following areas: * Interests, hobbies, social, leisure activities; * Spiritual, cultural preferences and traditions;* Visits to health practitioner(s), ER, hospital or NF in the past year;* Mental Health issues including: presence of depression, thought disorders or behavioral or mood problems; history of treatment; and effective non-drug interventions;* Personality: including how the person copes with change or challenging situations; and* Ability to use call system;* Recent losses; * Unsuccessful prior placements; * Elopement risk or history;* Smoking, ability to smoke safely; * Alcohol and drug use; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.The need to ensure Resident 1's evaluation was reflective of his/her health status, current needs and addressed all required components was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.4. Resident 4 was admitted to the facility in 04/2023 with diagnoses including Type 2 diabetes and Parkinson's Disease. Review of the initial evaluation dated 04/21/23 revealed the following elements were missing:* Spiritual, cultural preferences and traditions;* Personality: including how the person copes with change or challenging situations; and* Environmental factors that impact the resident's behavior including, but not limited to: noise, lighting and room temperature.The need to ensure the initial evaluation included all of the required elements was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3 and 4's current service plans were reviewed during the survey. On 06/14/23 at 11:00 am, Staff 1 (Administrator) confirmed the facility lacked documented evidence of a Service Planning Team to participate and review the individual service plan.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to notify the physician/practitioner when a resident refused consent to an order, for 1 of 1 sampled resident (#1) who had documented medication refusals. Findings include, but are not limited to:Resident 1 moved into the facility in 2021 and had diagnoses including chronic obstructive pulmonary disease and emphysema. Resident 1's MARs were reviewed for the time period of 05/01/23 through 06/12/23. Staff documented Resident 1 refused the following for the month of 05/2023:* Diltiazem (for blood pressure) on 22 occasions; * Escitalopram (for depression) on 13 occasions;* Furosemide (for pulmonary edema) on 13 occasions;* Hydralazine (for blood pressure) on 22 occasions; * Levothyroxine (for hypothyroidism) on 13 occasions;* Omeprazole (for stomach care) on 13 occasions; * Docusate (for constipation) on six occasions; * Ferrous sulfate (for iron deficiency) on 14 occasions; * Boost pudding (for muscle weakness) on 11 occasions; * Eliquis (for blood clot prevention) on 23 occasions; and* Levetiracetam (for seizures) on 21 occasions.Staff documented Resident 1 refused the following for the time period of 06/01/23 through 06/12/23:* Diltiazem (for blood pressure) on three occasions; * Hydralazine (for blood pressure) on three occasions;* Eliquis (for blood clot prevention) on one occasion; and* Levetiracetam (for seizures) on three occasions. In an interview on 06/13/23, Staff 4 (RCC) reviewed the record and acknowledged there was no documented evidence the facility had notified the physician/practitioner of the refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications for 2 of 2 sampled residents (#s 1 and 2) who were prescribed PRN medications for behaviors. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in 04/2016 with diagnoses including depression and anxiety. Resident 2 had a physician's order for Clonazepam 0.5 mg one twice daily as needed for anxiety.Review of MARs and progress notes, from 05/01/23 through 06/12/23, revealed staff administered PRN Clonazepam on 57 occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 on 06/14/23. They acknowledged the findings.
2. Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema. Resident 1 had a physician's order for Lorazepam 0.5 mg tablet by mouth four times daily as needed for agitation, anxiety or shortness of breath. Review of MARs from 05/01/23 - 06/12/23 revealed staff administered PRN Lorazepam on one occasion. There was no documented evidence staff attempted non-drug interventions with ineffective results prior to administering the psychotropic medication.In an interview on 06/13/23 at 1:00 pm, Staff 4 (RCC) reviewed the MAR and progress notes. She acknowledged staff did not document non-drug interventions attempted prior to administering the PRN. The need to ensure staff documented non-pharmacological interventions had been tried with ineffective results prior to administering PRN psychotropic medications was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use, documented other less restrictive alternatives prior to use, provided instruction to caregivers on correct use and precautions, and documented use of the rails in the resident's evaluation and service plan for 1 of 1 sampled resident (# 1) who had side rails. Findings include, but are not limited to:Resident 1 was admitted to the facility in 09/2021 with diagnoses including chronic obstructive pulmonary disease and emphysema.During an interview on 06/13/23 at 12:10 pm, Resident 1's hospital bed was observed to have half-length side rails on the left side of the bed. The side rails were in the up position and securely fastened to the bed.In an interview with Staff 1 (Administrator) on 06/13/23 at 4:30 pm, side rail assessment documentation was requested. There was no documented evidence the device with restraining qualities had been assessed by an RN, PT or OT, documentation of less restrictive alternatives prior to use, instruction to caregivers on correct use and precautions, and documentation of the use of the rails in the resident's evaluation and service plan.The need to ensure supportive devices with potentially restraining qualities were assessed prior to use and addressed all required elements was discussed with Staff 1 and Staff 2 (Owner) on 06/14/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure documentation that 4 of 4 sampled newly hired employees (#s 9, 10, 11 and 12) completed pre-service orientation and dementia care training prior to assuming their job duties. Findings include, but are not limited to:Staff training records were reviewed on 06/13/23. The following deficiencies were identified:a. Staff 9 (CG), hired 03/02/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training.b. Staff 10 (CG), hired 04/28/23, lacked documented evidence of having completed Infectious Disease Prevention and pre-service dementia training.c. Staff 11 (MT), hired 04/05/23, lacked documented evidence of having completed Infectious Disease Prevention training.d. Staff 12 (Waitstaff) was hired 05/22/23. There was no documented evidence Staff 12 completed the following training requirements:* Fire Safety and emergency procedures; and * Infectious Disease Prevention.The need to ensure staff completed pre-service training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23 at 3:30 pm. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 caregiving staff (#s 10 and 11) demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to:Training records were reviewed on 06/13/23.There was no documented evidence Staff 10 (CG) and 11 (MT), hired 04/28/23 and 04/05/23 respectively, had demonstrated competency in all required areas and within 30 days of hire including:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation, and reporting; and * General food safety, serving and sanitation.Additionally, there was no documented evidence Staff 10 had completed First Aid certification and abdominal thrust training within 30 days of hire.The need to ensure staff had demonstrated competence in all job duties within 30 days of hire and completed First Aid certification and abdominal thrust training was reviewed with Staff 1 (Administrator) and Staff 2 (Owner) on 06/13/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to include required components on fire drill records. Findings include, but are not limited to:Fire and life safety records, reviewed between 01/2023 through 06/2023, revealed the following:* Fire drill records lacked the following components:- Escape route used; - Problems encountered and comments relating to residents who resisted or failed to participate in the drills;- Evacuation time period needed;- Number of occupants evacuated; and - Evidence alternate routes were used during fire drills. In an interview on 06/13/23 at 2:45 pm, Staff 1 (Administrator) acknowledged fire drill records lacked the required components.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training annually. Findings include, but are not limited to:Fire and life safety records were requested during the survey. The following deficiencies were identified:* Documentation of annual fire and life safety training provided to residents.The need to ensure residents received fire and life safety training at least annually was discussed with Staff 1 (Administrator) on 06/13/23 at 2:45 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure pathways were maintained in good repair and did not have potential hazards. Findings include, but are not limited to:Observations of the outer courtyard surfaces and pathways on 06/12/23 showed the following:* Multiple drop-offs of 2-4 inches along pathway edges of the courtyard.The need to ensure pathways were maintained in good repair and did not have potential hazards was discussed with Staff 1 (Administrator) and Staff 2 (Owner) during a tour of the exterior grounds on 06/13/23 at 11:40 am. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure all interior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility was toured on 06/12/23. The following was observed: * Lower cabinets in the activity room were scraped/scuffed;* Cabinets in the dining room were scraped/scuffed;* Tables throughout the dining room were scraped on the edges;* Chairs throughout the dining room were scraped/scuffed;* Carpet in front of Room 109 was stained; * Baseboard that surrounded RCC desk area was scuffed; * Spills on the wall by the door to the outside in the hallway of Room 125; * Inside the elevator had boards around the base that were scuffed and gouged;* Multiple doors leading to the exterior had gouged, scuffed door jambs and doors; * A couch in the 2nd floor library was stained; and* A wall outside of Room 233 had gouges.The environment was toured on 06/13/23 at 11:40 am with Staff 1 (Administrator) and Staff 2 (Owner). They acknowledged the above areas needed to be cleaned and repaired.

The findings of the kitchen inspection, conducted 01/18/23, 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 first re-visit to the kitchen inspection of 01/18/23, conducted 04/27/23, 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.

Based on observation and interview, it was determined the facility failed to ensure food was prepared, and the kitchen was maintained, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:Observations of the facility kitchen, food storage areas, food preparation, and food service on 01/18/23 revealed splatters, spills, drips, and debris noted on: - Stand mixer; - Exterior sides and behind the gas range and oven; - Walls throughout the kitchen; - Flooring throughout the kitchen; - Cookware stored on open shelving and racks; - Open shelving and metal rack shelving; - Bakery racks; - Underneath shelving and equipment throughout kitchen; - Triple pot sink area; and - Dishwashing area including flooring, walls, and equipment.* Raw chicken was left in a bucket of standing water in the sink.* The laminate to the tray line was damaged creating an uncleanable surface.* A scoop was left with the handle in the flour.* Box of food was stored directly on the floor in the walk-in freezer.* There were undated and unlabeled foods in all refrigerators. * The chemical sanitizer for the low temperature dish machine was not monitored to ensure it was reaching the required level. * Dish washing racks were stored on the floor. * Staff were using a Quaternary solution for sanitizing towels. There was no evidence of testing the solution to ensure it was between 150 and 200 parts per million. * Dietary Staff were observed to not change gloves between tasks during food preparation and service.* Dietary Staff did not wash hands upon entry to the kitchen.* Dietary Staff did not have long hair restrained.Staff 3 (Dietary Manager) and the surveyor toured the kitchen. She acknowledged the findings. The areas in need of cleaning and repair, food storage, sanitation and hand hygiene were reviewed with Staff 1 (Executive Director) and Staff 2 (Facility Owner) on 01/18/23.