Faye Wright Senior Living

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).

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with the Food Sanitation Rules, OAR 333-150-000. Facility also failed to ensure residents receiving puree textures meals were nutritious and menus were followed. Findings include, but are not limited to: 1. Observation of the main food prep kitchen and individual house kitchens on 07/22/25 at 11:15 am through 3:00 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: Main Food Prep Kitchen (960) * Walls * Removable hood vents * Kitchen drains * Floors under/behind equipment * Industrial Can opener and housing * Shelving in dry storage area * Ceiling vent above food preparation areas House 950 * Ceiling vents * Industrial can opener and housing * Industrial mixer * Removable hood vents * Ovens * Windowsill House 940 * Industrial can opener * Removable hood vents * Reach in refrigerator House 920 * Reach in refrigerator * Walls/Ceiling with dust and dirt build up * Stainless steel shelving * Drain *Windowsills/windows House 910 * Reach in refrigerator * Windowsill Food storage area in House 960 * Carpet with dirt and heaving staining b. The following was observed needing to be repaired. *Caulking around hand washing sink was cracked/missing or had black substance build up. * House 960 dry storage area with wood shelving with damage to shelving exposing porous wood areas * Reach-in refrigerators/coolers in house 960 with seals off/damaged/needing repair * Large hole in house 950 in dry storage area in back entry way. Hole was directly above dishes/utensils/equipment that was stored. * Hand washing sink pulling away from wall leaving large gap * Multiple metal worktables bottom shelves were found/observed worn with metal rusting/corroding * Utility sink faucet in house 950 observed with a leak spraying water onto the windowsill c. Staff food item was observed stored with resident food. d. Ice machine in house 910 was observed with lid open exposing ice to potential contamination. Ice machine was located next to a window which was open and screens and windowsills were very dirty. e. Staff 2 was designated person in charge and was not able to effectively demonstrate knowledge in potential illnesses that would be excludable and reportable as per food code. Staff 2 was also not able to demonstrate appropriate knowledge in required reheating temperatures or cooling time and temperature guidelines. f. Residents who received puree textures were not provided a vegetable for the meal observed. The posted menu stated mixed vegetables should be served along with the chicken and potatoes. The residents receiving puree texture were not provided an appropriate alternative to ensure similar nutritional value of meal served. Staff 2 was interviewed and acknowledged residents receiving puree textures were not prepared or served vegetables that meal and stated their blender (robo coupe) didn’t puree certain vegetables well to get a good puree texture. Staff 2 acknowledged an alternative vegetable was not served. g. Puree meal included puree chicken and mashed potatoes. Both items were white/colorless and looked similar. No garnishes were used and no color contrasts were served to distinguish one food item from the other. Puree meals were served in separate bowls and not on a plate like other diet types. Staff 2 was interviewed and indicated they have just always served puree in separate bowls. Staff 1 (Executive director) was interviewed and verified the residents receiving puree did not have any service planned needs or instructions for serving foods in separate bowls. Neither Staff 1 or Staff 2 was able to state a clinical reason for serving food in separate dishes to residents with puree textures. Staff 1 and Staff 2 acknowledged the meal served during survey was not visually appealing and was served differently than other residents without appropriate indication or resident request to do so. h. Multiple buildings/houses kitchen areas had a restroom in the kitchen area that were observed to have the door to the restroom open including during meal service Times. Food code requires rest room doors to be kept closed except when cleaning. i. Kitchens did not have dedicated hand washing sinks as required. Kitchens were using a utility sink for hand washing. These sinks were also used for dish washing and other purposes. Food code requires a dedicated hand washing sink. Multiple houses the traditional hand washing sink was noted to be dirty/damaged or not operational or did not have appropriate supplies. House 920 sink had dirty dishes observed in sink where staff were observed to wash their hands on top of the dishes. j. Main food prep kitchen (house 960) observed with door to outside propped open. No screen or netting observed to prevent potential insects or pests from entry to kitchen area. k. Multiple house kitchens were observed with recyclables not stored in appropriate containers that were lined, washable and covered to prevent potential accumulation or attraction of pests as outlined in Food Sanitation rules. l. Dishes/equipment were not stored covered or inverted and protected from potential contamination. m. Multiple sauté pans in house 950 were worn, chipped, scrapped or observed with cooked on brown/black carbon debris on food contact surface. n. Multiple trays of food were observed served to residents without food or beverages covered and protected from potential contamination in houses 920 and 910. o. Sanitizing solution for 3 compartment sink was tested in house 910 chemical was a Quaternary ammonia (QUAT) solution distributed from a wall unit. When tested using facility provided and surveyor test strips 0 parts per million (PPM) was noted. Staff 1 validated no PPM on strips and investigated the wall dispensing unit and discovered the lid was not attached properly. Staff in kitchen area were unsure how long the chemical was not dispensing correctly. Facility did not have a system in place to ensure chemical concentration was tested frequently to ensure operating correctly. At approximately 2:30 pm surveyor reviewed above areas with Staff 1 who acknowledged identified areas.

1. Culinary Services Director (CSD) and culinary services staff will be educated by the Executive Director (ED) or designee on the following by: a. Daily, weekly, and monthly cleaning schedules b. Foodborne illnesses and reporting c. Reheating and Cooling guidelines for food safety. d. Pureed/altered diets procedures; menu spreadsheets for altering textures; and visually appealing plating techniques. e. Infection control practices to include handwashing and restroom door closure; storage of dishes and food delivery practices to prevent contamination. f. Sanitizing test strip usage and logs. 2. All staff will be educated by the ED/CSD on food delivery practices to prevent contamination. 3. The identified areas were cleaned and/or repaired by the Culinary Services Team and designees by 9/20/25. 4. The ED or designee will perform a weekly CBC kitchen walkthrough x 2 months, and then monthly x 3 months. 5. The CSD or designee will audit the cleaning schedules at least 3 times per week x 1 month, weekly x 1 month, and then monthly x 2 months to maintain compliance.

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).

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 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.

1. Culinary Services Director (CSD) and culinary services staff will be educated by the Executive Director (ED) or designee on the following by: a. Daily, weekly, and monthly cleaning schedules b. Foodborne illnesses and reporting c. Reheating and Cooling guidelines for food safety. d. Pureed/altered diets procedures; menu spreadsheets for altering textures; and visually appealing plating techniques. e. Infection control practices to include handwashing and restroom door closure; storage of dishes and food delivery practices to prevent contamination. f. Sanitizing test strip usage and logs. 2. All staff will be educated by the ED/CSD on food delivery practices to prevent contamination. 3. The identified areas were cleaned and/or repaired by the Culinary Services Team and designees by 9/20/25. 4. The ED or designee will perform a weekly CBC kitchen walkthrough x 2 months, and then monthly x 3 months. 5. The CSD or designee will audit the cleaning schedules at least 3 times per week x 1 month, weekly x 1 month, and then monthly x 2 months to maintain compliance.

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, interview, and record review, it was determined the licensee failed to provide effective oversight to ensure the quality and care of services rendered in the facility. Findings include, but are not limited to: During the change of ownership survey, conducted 03/04/24 through 03/07/24, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective, based on the number and severity of citations. Refer to the deficiencies in the report.

ED will implement a nursing follow-up spreadsheet to be used by HSD/designee by 4/15/24. ED will audit the spreadsheet at minimum twice a month to ensure tasks have been completed. The nursing follow-up spreadsheet is a tool used where the HSD/Designee can track audit results of clinical items listed in this POC. ED will work with all other Department Managers to ensure the plans listed in this statement of Deficiency.(SOD) ED will train other managers on this POC and their expectations by 4/5/2024 ED/HSD/Designee will provide continuous training for all staff by holding a training meeting every quarter to review relevant topics first meeting to be held by 5/5/24.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of 2 of 5 sampled residents (#s 3 and 4) related to disposable razor storage and residents who required altered diet textures due to aspiration and choking risk. Residents 3 and 4 received inaccurate food textures which caused them to choke and placed them at risk for aspiration, additional choking events and/or avoidable hospitalization. Findings include, but are not limited to The International Dysphagia Diet Standardization Initiative (IDDSI) describes a Soft & Bite Sized (Mechanical soft) diet, as a Level 6 diet and a Minced & Moist diet, as a level 5 diet. A Minced & Moist diet is more restrictive than a Level 6. The individual diets included the following characteristics: * Mechanical Soft-soft, tender and moist, but with no thin liquid leaking/dripping from the food. Ability to bite off a piece of food is not required, but the ability to chew bite-sized pieces so that they are safe to swallow is required. Bite-sized pieces no bigger than 1.5 cm x 1.5 cm in size, food can be mashed/broken down with pressure from a fork, and a knife is not required to cut this food. * Minced & Minced-soft and moist, but with no liquid leaking/dripping from the food. Biting is not required, minimal chewing is required, can have lumps up to 4 mm in size and lumps can be mashed with the tongue. The food can be easily mashed with just a little pressure from a fork, should be able to scoop the food onto a fork with no liquid dripping and no crumbles falling off the fork. 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia and stroke. The service plan, dated 12/01/23, and progress notes, temporary service plans, speech therapy notes, and physician communications dated 12/04/23 through 03/05/24 were reviewed and showed the following: * A speech therapy note dated 01/22/24 indicated the resident required mechanical soft textures with extra moisture. * A progress note dated 01/28/24 indicated the resident had a choking episode at lunch, the medication technician "got food out of throat." There was no other information about the incident. No investigation of the choking incident was completed. * A progress note dated 01/31/24 indicated "more and more choking episodes." There was no other information regarding the incident. * A speech therapy note dated 02/06/24 indicated the resident was trailed on minced moist textures. The resident was noted to shovel foods into his/her mouth. Interventions to slow the resident's intake were unsuccessful due to the resident's cognition and difficulty understanding. The speech therapist recommended a diet downgrade to minced moist, but the resident could continue with thin liquids. * A speech therapy note dated 02/16/24 indicated the resident was consuming moist, mechanical soft textures. There were no overt signs or symptoms of aspiration. * A speech therapy discharge note, dated 02/26/24, indicated the resident continued with moist mechanical soft textures and thin liquids.   * The current service plan was not reflective of the speech therapy recommendations, the resident's "shoveling" of foods, or the diet textures directed by the therapist. * The Resident Diet Roster Report, printed on 03/04/24 and available for kitchen staff,  indicated the resident received "soft texture, minced/moist foods." * Meal observations were completed for lunch and snack on 03/04/24, and breakfast and lunch on 03/05/24 and 03/06/24. The 03/04/24 lunch meal observation showed the resident received cooked green beans, uncut fettuccine noodles with minimal sauce and large chunks of chicken cordon bleu. The resident received multiple cups of fluids. The resident ate 100% of the lunch meal. S/he ate the meal very quickly, using both hand and utensil to get food into his/her mouth. The resident intermittently alternated foods with the fluids. Snack was provided to the resident after interviews with Staff 2, 6, and 9 about ordered diet texture. The resident was given a medium sized oatmeal cookie by Staff 11 (CG). Observation of the resident showed s/he rapidly ate the cookie. The resident alternated with fluids and cleared throat with two small coughs in between bites. The resident was given a bowl of yogurt by kitchen staff shortly after the cookie was given and stated the resident needed soft items. In an interview on 03/04/24, Staff 6 (Cook) indicated the resident received a mechanical soft texture. She was unaware of what the diet roster said or what minced moist would be. In an interview on 03/04/24, Staff 2 (Health Services Director/LPN) and Staff 9 (Dietary Manager) indicated they thought minced moist was the same as mechanical soft textures. Staff 9 was not sure their facility even offered minced moist as a diet texture option.  Staff 2 and Staff 9 agreed that typically the care staff would let them know if they needed to adjust the resident's diet texture or if the items served in the meal were difficult for the resident. Staff 2 and Staff 9 were advised the resident received long, uncut fettuccine noodles as well as large chunks of cordon bleu chicken for lunch. The staff acknowledge the chicken did not meet a minced, moist or mechanically soft diet. Staff 2 was unaware the resident had an actual choking incident. In interview on 03/04/24, Staff 11 indicated the resident had mechanical soft foods. He gave the resident the cookie for snack because it was soft. Staff 11 was not aware of any problems related to the resident choking. In interviews on 03/04/24, Staff 10 (CG), Staff 12 (MT), and Staff 14 (CG) indicated the resident ate very well. They were unaware of any choking problems. The staff indicated the resident was given soft, easy-to-chew items for meals and snacks. Staff 3 (RN) was unaware of the choking incident noted in the progress notes or what the resident's diet texture was. Staff 1 (ED) indicated a choking incident should have an investigation to figure out what occurred. He was unable to locate any investigation of this incident or investigations regarding increased choking noted in the progress notes. The resident had multiple choking incidents noted near the end of January with no investigation to determine if the resident received the proper assistance and diet texture. Staff were observed to give the resident the wrong diet textures at the time of survey and continued to give inappropriate food items until the surveyor intervened. There was no documentation to reflect any interventions implemented or monitoring completed related to the previous choking incidents and updates made to the resident's care needs. The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/04/24 and 03/06/24. The staff acknowledged the findings. 2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. Observations were made, interviews conducted, and progress notes, service plan and temporary service plans dated 12/04/23 through 03/05/24 were reviewed. The following was identified: a. On 02/22/24 the resident returned to the facility after being admitted to the hospital on 02/18/24. S/he had been diagnosed with having a stroke, and had been admitted to hospice. Hospice updated his/her orders, including placing an order for diet texture modification to "minced and moist." A progress note from 03/03/24 stated "Resident has had slurring of words today" and "Had trouble swallowing". During the survey dates 03/04/24 through 03/06/24, the resident was observed requiring varied levels of feeding assistance, at times feeding him/herself, while other times requiring cueing or hand to mouth feeding assistance from staff. Staff stated that s/he did not have a modified diet texture. The resident was observed being served meals which were not modified with items including plain dinner rolls, penne pasta with minimal sauce, and salad with iceberg lettuce . The resident was not observed actively coughing or choking during the survey. During an interview with Staff 1 (ED), Staff 2 (Health Services Administrator/LPN) and Staff 3 (RN) on 03/06/24, they stated they were unaware of the need for a modified diet for Resident 3, and that "minced and moist" is not a diet they offer. They stated they were unaware of the changes to his/her needs for meal assistance and difficulty swallowing. Staff 2 stated she would evaluate the resident and contact hospice to make sure the resident received the appropriate diet moving forward. b. On 03/04/24, the resident was observed sitting in his/her wheelchair in his/her room, and verbally agreed to speak with this surveyor. The resident stated s/he would like a drink of juice, and was going to look in his/her "cookie drawer". The resident reached over and opened the third drawer on his/her dresser. Inside the drawer was a can of soda, a container of apple juice, two plastic bags of cookies, and a plastic bag containing four disposable razors. One of the razors appeared to have been used and was missing the safety cover. Resident 3 stated s/he was unaware who the razors belonged to or why they were in the drawer with his/her food. Surveyor asked Staff 30 (MT) to safely store the razors, and she placed them in the med room. She stated she did not know if the razors belonged to this resident or another resident, or how long they had been in his/her snack drawer. Two other staff were interviewed and were unable to provide any additional information. Resident 3's most recent evaluation, dated 12/22/23, stated resident "gets confused easily", decision-making is "severely impaired", and the resident has "severe cognitive impairment". Under grooming and shaving, the evaluation stated the resident was "total assist" and "requires a total one staff assist in shaving [his/her] face." The need to ensure reasonable precautions are exercised against any condition which could threaten the health, safety or welfare of residents was discussed with Staff 1 and Staff 2 on 03/04/24 and 03/06/24. They acknowledged the findings.

HSD/Designee reviewed and clarified resident # 4's diet on 3/14/24. HSD/CSD were reeducated the kitchen staff on mechanical soft diet on 3/7/24 by the National Director of Culinary Services. Razors were immediately removed from resident's #3 room on 3/6/24. All resident rooms were checked in memory care for potentially dangerous items and removed placed in storage on 3/20/24 by RCC. HSD/Designee will audit all resident diet orders and obtain clarifications orders on approved diet order form and input new orders,if any, into EHR system by 4/15/24. ED/Designee will ensure a new diet board system, one where kitchen staff will be made aware of diet changes by HSD will be implemented in all kitchens by 4/15/24. ED/Designee will notify all POA's/represenatives of the need to have all potentially dangerous items checked in with HSD/Designee when bringing them in by 4/15/24. ED/HSD/Designee will reeducate alll staff on mechanical soft diets and potentially dangerous items such as razors for their proper storage in Memory care by 4/15/24. Safety Room checks will be conducted in the Memory care unit starting 3/20/24, 3x weekly ,x4 weeks, then weekly x4 weeks,then monthly ongoing. Results of audits will be reported to QAPI Director and committee monthly

Based on observation, interview, and record review, it was determined the facility failed to ensure residents were treated with dignity and respect and had a homelike environment for 1 of 1 sampled resident (#5) and two unsampled residents. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. His/her service plan, dated 10/09/23, stated, "Staff are to feed [Resident] at all times, as [Resident] is unable to feed [him/herself]." Staff stated the resident would attempt to feed him/herself but was not able to use utensils and had to be fed hand-to-mouth at all meals. Staff stated the resident was not able to communicate his/her needs verbally. On 03/04/23, the resident was observed seated at a dining room table for lunch. A caregiver was seated nearby and assisted the resident with eating from 12:37 pm to 12:45 pm. The food consisted of mixed rice, mashed beans, and cut up chicken. The caregiver left the table at 12:45 and did not return until 1:15 pm. During those 30 minutes, the resident was not assisted by a staff member. S/he attempted to eat with his/her hands, resulting in greater than 50% of the meal on his/her hands, face, and clothing protector. The need to ensure residents were treated with dignity and respect, including assisting with meals, was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings. 2. On 03/05/24, multiple staff members approached the survey team to discuss the lack of hot water in the shower in building 940, room 2. Staff stated two residents had not been able to shower in their room, room 2, for approximately one month as there was no hot water in the shower. The building did have a community bathroom with a shower, but it was inaccessible. When the survey team attempted to observe the community shower room, the door was unable to be opened fully due to the amount of large storage items stacked in the room, and there was a significant odor of sewage coming from the room. Staff stated that the two residents in room 2 had been offered to shower in other resident's rooms but the residents had not felt comfortable with this and had been repeatedly declining to shower. During interviews on 03/05/24 and 03/06/24, Staff 1 (ED) and Staff 4 (Maintenance Director) stated they were aware of the lack of hot water in room 2, but were not aware of the impact on the residents' ability to shower due to the lack of available community shower room and would address the situation. On 03/07/24, the survey team verified that the community shower room had been cleaned and the residents had access to the private shower area which had hot water. All storage items had been removed and the odor had dissipated. The need to ensure residents were treated with dignity and respect and had access to a homelike environment was reviewed with Staff 1 and Staff 4 on 03/05/24. They acknowledged the findings.

Resident #5 was reassessed by HSD and TSP completed on 3/6/24 as it relates to diet change to finger foods. RN Delegation nurse completed change of conditon note and assessment on 3/20/24. Staff was immediately educated on assisting resident #5 with meal assistance on 3/7/24 by the HSD. Community shower room was clean and made accesibile for use on 3/7/24. All staff will be reeducated during an inservice on resident rights by ED/HSD/Designee by 4/15/24. Unit safety checks to include shower room checks will be conducted 3x per week x 4 weeks, then weekly ongoing started on 3/20/24. BOM/Designee will audit all employee files by 4/15/2024. Any missing information will be obtained by 4/30/2024. The BOM/designee will audit 10% of employee files monthly for compliance. All staff will be educated by the ED on the resident bill of rights, and dignity/respect. All incidents and altercations that involved residents #3,4,5,6 were immediately reported to APS on 3/7/24. ED/HSD/Designee were reeducated on Oregon State requirements and regulations for reporting and investigating incidents of unknown origin and interactions between residents on 3/21/24. All staff will complete abuse and neglect training through Oregon Care Partners by 4/30/24 ED/HSD/Designee will review incident log report/observation notes at least 3 x's/week. A complete investigation will be done with each incident and incidents will be reported within the timeline as required. Results of audits will be reported to QAPI Director and committee at next scheduled meeting.

Based on observation, interview, and record review, it was determined the facility failed to ensure incidents were promptly investigated to rule out abuse and neglect and reported to the local SPD office when required, for 6 of 7 sampled residents (#s 3, 4, 5, 6, 7 and 8). Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including stroke. Observations of the resident, interviews with staff, and review of the resident's 12/01/23 service plan, 12/04/23 through 03/05/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident required extensive assistance with his/her ADL care. The resident was primarily non-verbal but could make some needs known through gestures, simple yes/no questions, or selection between two choices. The resident moved from the assisted living portion of the facility to the memory care in December 2023. Review of the resident's records showed the following: * An incident investigation dated 01/13/24, indicated Resident 4 wandered into another resident's room and struck them in the arm. Staff were present and removed Resident 4 from the room. There was no documentation the resident altercation was reported to the local SPD office. * An incident investigation dated 01/14/24, indicated Resident 4 was found grabbing hold of another resident's arms who had entered his/her room. Staff separated the two residents. There was no documentation the resident altercation was reported to the local SPD office. * A progress note dated 01/28/24, indicated the resident experienced a choking episode and the medication technician "got the food out of (his/her) throat." No investigation was completed regarding the incident to rule out abuse and neglect. * A progress note dated 02/06/24 indicated Resident 4 had physical altercations with two different residents. No investigation was completed, and no report was made of the altercations to the local SPD office. * An incident investigation dated 02/14/24, indicated Resident 4 was found hitting and pushing another resident. There was no other information noted on the report. There was no documentation the resident altercation was reported to the local SPD office. *  An incident investigation dated 02/16/24, indicated Resident 4 grabbed another resident and pushed them. No other information about the incident was noted. There was no documentation the resident altercation was reported to the local SPD office. * An incident investigation dated 02/25/24 indicated Resident 4 and another resident were hitting each other while in the dining room. There was no other information regarding the incident. There was no documentation the resident altercation was reported to the local SPD office. The facility reported the incidents to the local SPD office at the time of survey on 03/07/24. A confirmation of the reports was provided to the survey team prior to exit. The need to ensure resident altercations and incidents were investigated and reported to the local SPD office was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including diabetes. Observations of the resident, interviews with staff, and review of the resident's 12/12/23 service plan, 11/17/23 through 03/06/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. The resident required extensive assistance with his/her ADL care. The resident could make his/her needs known and direct his/her own care. The resident could move in a wheelchair around the facility on his/her own, but staff frequently moved the resident to whatever area s/he needed to be. Staff provided one- to two-person assistance with the wheelchair or a walker. The resident had some confusion and could get agitated with staff when things were not done how and when s/he directed. Review of the resident's records showed the following: * A progress noted dated 12/14/23 indicated the resident had swelling to the right-hand, middle finger. No investigation was completed, and no report was made to the local SPD unit regarding the injury. * A progress note dated 12/21/23 indicated the resident reported their roommate was cursing at them and going through his/her personal belongings. No investigation was completed regarding the roommate concerns and no report was made to the local SPD office. * A progress note dated 12/27/23 indicated the resident's big toenail was split and had some cloudy discharge. No investigation was completed, and no report was made of the injury of unknown cause to the local SPD office. * A progress note dated 02/12/24 indicated the resident sustained a skin tear to the left thumb on 02/05/24. No investigation was completed, and no report was made of the injury of unknown cause to the local SPD office. * A progress note dated 02/20/24 indicated the resident had a skin tear to the left lower arm. No investigation was completed, and no report was made of the injury of unknown cause to the local SPD office. * An incident investigation dated 02/29/24 indicated the resident was found to have a skin tear on the right hand. The resident indicated s/he caught the hand on the door while grabbing a water bottle. There was no other information regarding the injury to rule out abuse and neglect. The facility reported the incidents to the local SPD office at the time of survey on 03/07/24. A confirmation of the reports was provided to the survey team prior to exit. The need to ensure resident altercations and incidents were investigated and reported to the local SPD office as needed was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 12/22/23 service plan, 12/04/23 through 03/05/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. Review of the resident's records showed the following: * 12/04/23 - Skin tear to left elbow and left knee; and * 02/02/24 - Unwitnessed fall with injury to R forearm. There was no documentation that either incident was investigated and abuse or neglect ruled out. The facility reported the incidents to the local SPD office at the time of survey on 03/07/24. A confirmation of the reports was provided to the survey team prior to exit. The need to ensure resident altercations and incidents were investigated and reported to the local SPD office as needed was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 4. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's 10/09/23 service plan, 12/04/23 through 03/05/24 temporary service plans, progress notes, physician communications, and incident investigations were completed. Review of the resident's records showed the following: * 01/10/24 - Discoloration of left finger; * 01/17/24 - Scratches to right and left shoulders; * 01/24/24 - Bruising to left wrist and upper right chest; * 01/26/24 - Redness and bruising to middle/right side of back; * 01/31/24 - Contusion to left hand; and * 03/02/24 - Skin tear to left wrist. There was no documentation that the injuries of unknown cause were investigated and abuse or neglect ruled out. The facility reported the incidents to the local SPD office at the time of survey on 03/06/24 and 03/07/24. A confirmation of the reports was provided to the survey team prior to exit. The need to ensure resident altercations and incidents were investigated and reported to the local SPD office as needed was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 5. Resident 7 was admitted to the facility in 10/2021 with diagnoses including dementia. Resident 8 was admitted to the facility in 10/2023 with diagnoses including dementia. During the acuity interview on 03/04/24, Staff 2 (Health Services Director/LPN) and Staff 27 (RCC) stated they were unaware of any residents currently engaging in intimate contact together. On 03/04/24, Resident 7 and Resident 8 were observed cuddling on the couch and holding hands. Staff stated the two residents had been engaging in physical contact over the past few weeks. Staff described having to intervene due to "kissing to the point of it bothering other residents" and "straddling each other." Staff stated they believed there had been touching of private areas, and staff were trying to make sure the residents did not have blankets or sweatshirts covering their laps while they were together. During an interview with Staff 1 (ED) and Staff 2 on 03/06/24, they stated they were unaware of the extent of the physical relationship. They were unable to provide any documentation that the physical interactions had been investigated and abuse/neglect ruled out.   The facility reported the incident to the local SPD office at the time of survey on 03/07/24. A confirmation of the reports were provided to the survey team prior to exit. The need to ensure resident interactions were investigated and reported to the local SPD office was discussed with Staff 1 and Staff 2 on 03/06/24 and 03/07/24. The staff acknowledged the findings.

All incidents and altercations that involved residents #3,4,5,6 were immediately reported to APS on 3/7/24. ED/HSD/Designee were reeducated on Oregon State requirements and regulations for reporting and investigating incidents of unknown origin and interactions between residents on 3/21/24. All staff will complete abuse and neglect training through Oregon Care Partners by 4/30/24 ED/HSD/Designee will review incident log report/observation notes at least 3 x's/week. A complete investigation will be done with each incident and incidents will be reported within the timeline as required. Results of audits will be reported to QAPI Director and committee at next scheduled meeting.      All staff will complete abuse and neglect training through Oregon Care Partners. ED/HSD/RCC and Med Techs will be educated on the incident reporting expectations, investigations, and administrator review by the Regional Director of Operations and the Regional Director of Health Services. Incidents and observation notes will be reviewed by the ED/HSD/Designee at least 3 x's/week to investigate and report timely.

Based on observation, interview, and record review, it was determined the facility failed to provide a daily program of social and recreational activities based upon individual and group interests, physical, mental, and psychosocial needs, and opportunities for active participation in the community at large. Findings include, but are not limited to: During the survey, conducted 03/04/24 through 03/07/24, observations were made in all four resident-occupied buildings (Building #s 910, 920, 940, and 950), as well as Building 930. On 03/05/24, a religious activity was held in Building 930 for any residents who wished to attend. No other large group activities were observed. Small groups of residents were observed participating in activities sporadically in Buildings 910, 920, 940, and 950. The posted activities calendar in each building was not followed. Multiple care staff were interviewed between 03/04/24 and 03/07/24, from all four buildings, regarding activities in the buildings. Care staff reported they did not conduct activities with residents. On 03/07/24, Staff 37 (Activities Assistant) reported she did what she could with the residents but spent about half of her time doing other job duties. The need to ensure a daily activity program was provided for residents to address their mental, physical, and psychosocial needs was reviewed with Staff 1 (ED) on 03/06/24. He acknowledged the findings.

ED/Life Enrichment Director/Designee will be reeducated on activities/programming and following the calendar of daily programming by National Program Director by 4/15/24. ED/Life Enrichment Director/Designee will reeducate all staff on programming and activity calendar by 4/15/24. ED/Designee will audit activities in all community houses daily x4weeks then weekly x3 months until compliance is met. Results of audits will be reported to QAPI Director and committee at next scheduled meeting.

Based on interview and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements and addressed sufficient information to develop an initial service plan to meet the resident's needs for 1 of 1 sampled resident (# 2) who was recently admitted to the facility, and the most recent quarterly and/or change of condition evaluations were updated and reflective of the residents' current needs for 3 of 5 sampled residents (#s 2, 3, and 5) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including diabetes, lower extremity cellulitis, congestive heart failure, and morbid obesity. Review of the move-in evaluation, dated 11/02/23, identified the following required elements were not documented as being addressed: * Physical Health Status: vital signs, documented as indicated; * Skin conditions present; * List of treatments; * History of dehydration or unexplained weight loss or gain; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. A change of condition evaluation was completed on 11/15/23 after Resident 2 sustained a fall with a left ankle fracture. The evaluation was not updated to reflect the resident's current functioning status to meet the resident's needs in multiple areas. The need to ensure the initial move-in evaluation contained all required elements and change of condition evaluations were reflective of the resident's current needs was reviewed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/07/24. They acknowledged the findings. Staff 1 (ED) declined participation in the findings discussion. No further information was provided. 2. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. The resident's 12/22/23 quarterly evaluation was reviewed and interviews were conducted. There was no documentation the evaluation was updated with a significant weight loss, which occurred 02/02/24, or a significant change of condition related to increased assistance following a stroke on 02/18/24. Multiple areas of the evaluation did not describe Resident 3's physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not relevant to the resident's current condition, including: * Diet texture; * Recent hospitalization; * Assistance required with meals, evacuation, transfers, bathing, toileting, and ADLs; * Ambulation and assistive devices; * Skin condition; * Speech and communication: * Activity participation; and * Fall risk. The need to ensure evaluations are updated with significant changes of condition and described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings. 3. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. The resident's most recent evaluation, dated 10/09/23, was reviewed and interviews were conducted. There was no documentation the evaluation had been updated quarterly. Multiple areas of the evaluation did not describe Resident 3's physical and mental status, environmental factors which helped the resident function at his/her optimal level, and/or were not relevant to the resident's current condition, including: * Diet texture; * Ambulation; * Activity participation; * Skin condition; * Hospice; and * Weight loss. The need to ensure evaluations were updated at least quarterly and described resident's physical health status, mental status, and the environmental factors that helped the resident function at their optimal level, and were relevant to the current needs and condition of the resident was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings.

Resident #2 no longer resides in community. RN Delegation nurse will have Resident #3 & #5 evaluations updated to reflect significant changes of condition and will describe resident's physical health status by 4/1/24. HSD/Designee will audit all resident records for care plan completions. Careplans will be updated on Residents (3,4,5,6) by 4/15/24. Regional Nurse will reeducate ED/HSD/Designee were on creating a comprehensive & accurate care plan to meet resident needs by 4/1/24. ED/HSD/Designee will complete Person Centered Care plans for Dementia and Care Planning in Assisted Living in Relias by 4/15/24. HSD/Designee will review resident evaluations/CP reports weekly to ensure care plans are completed & accurate x4 weeks then quarterly,ongoing. Audit results will be reported to QAPI Director and committee at next scheduled meeting. ED/HSD/Designee were reeducated on evaluation completion on admission, within 30 days, quarterly and with condtion change per regulations by Corporate Director of Policy and Survey on 3/21/24. HSD/Designee will review resident evaluation report from EHR system weekly to ensure completion of evaluations, weekly and ongoing. Results of audits will be reported to QAPI Director and committee at next scheduled meeting.

2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia and stroke. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/01/23, and progress notes, dated 12/04/23 to 03/05/24, were completed. Staff indicated the resident required assistance with all ADL care. The resident could make some needs known, but staff did not rely on the resident's requests to provide care. The resident was primarily non-verbal but could answer very simple yes/no questions, use gestures, or pick from two choices given. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented in the following areas: * Altercations and aggression towards other residents; * Refusal of care and combative with staff; * Toileting assistance and incontinence care; * Diet texture, fluids and assistance needs; * ADL assistance; * Right hand range of motion limitations, hand cleaning, and use of hand grip; and * Activities for enjoyment and behaviors. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including dementia and congestive heart failure. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/12/23, and progress notes, dated 11/17/23 to 03/06/24, were completed. Staff indicated the resident required assistance with all ADL care. The resident could make needs known and direct his/her own care. The resident could become very irritated with staff if they did not do things when and how the resident directed. The resident would send staff away if s/he became too agitated. The resident's service plan was not reflective, lacked resident specific direction for staff, and/or was not implemented in the following areas: * Air bed, edema, and skin needs; * Refusal of care and agitation with staff; * Toileting assistance, incontinence care, and urinal use; * Wheelchair vs. walker use and footrests for wheelchair; * Fluid restrictions, no juice to be given, and heart failure concerns; * Pacemaker and monitor; * Hypoglycemia/Hyperglycemia concerns and CPAP use; * Diet texture, fluids, and assistance needs; * Shaving, grooming, bathing, and dressing assistance; * Evacuation assistance related to wheelchair vs walker; * One-person vs. two-person transfer and gait belt use; * Activities for enjoyment and behaviors. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff and were consistently implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction for staff, and/or were implemented for 5 of 5 sampled residents' (#s 2, 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including diabetes, polyarthritis, cellulitis of the left lower extremity, and had sustained a fall with left ankle fracture after admission to facility. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 11/07/23, and progress notes, dated 11/07/23 to 03/04/24, were completed. The resident was observed to receive two-person assist with bed mobility, dressing, incontinence care, and transfers using a Hoyer lift. Staff indicated the resident was bed-bound since the fall with fracture, was provided bed baths only, ate all meals in bed, and with set-up assistance could comb his/her own hair and brush his/her teeth. The resident could make his/her needs known and would call for additional staff assistance as needed. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or interventions were not implemented in the following areas: * Non-weight bearing right foot; * Walking boot to right foot when in wheelchair; *  Two-person Hoyer transfer; * Wheelchair for mobility to appointments; * Bathing status; * Skin conditions, treatments, and interventions; * Increased protein; * Ability to use key to room; * Outside provider services, RN; * Side rails on bed with safety monitoring directions; * Pressure-reducing pad in wheelchair seat; * Bed-bound by preference; * Pain in right lower leg, foot with interventions; * Meals in room with set-up assist; * Evacuation assistance; * Fall history with interventions as indicated; * Recent losses with interventions; and * Ability to use call system. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff,  and/or were implemented was discussed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/06/24. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/22/23, and progress notes and temporary service plans dated 12/03/23 to 03/04/24 were completed. The resident experienced a stroke on 02/18/24 which significantly changed his/her care needs. Staff indicated the resident now required two-person assistance with all ADL care including transfers, toileting, and grooming. The resident could not consistently make needs known to direct his/her own care. The resident's service plan was not reflective, lacked resident specific direction for staff and/or was not implemented in the following areas: * Diet texture; * Ambulation and assistive devices; * Assistance required for meals, toileting, transfers, evacuation, showering, and ADLs; * Adaptations needed for activity participation; * Hospice admission; * Geri-sleeves; * Pressure relieving mattress; and * Speech and communication. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 10/09/2023, and progress notes and temporary service plans dated 12/03/23 to 03/04/24 were completed. Staff indicated the resident required two-person assistance with all ADL care including transfers, toileting, and grooming. The resident was non-verbal and unable to make needs known to direct his/her own care. The resident's service plan was not reflective, lacked resident-specific direction for staff, and/or was not implemented in the following areas: * Diet texture and meal assistance; * Assist required for evacuation; * Speech and communication; * Resistance to care; * Ambulation; * Activity participation; * Skin condition; * Hospice; and * Weight loss. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were consistently implemented was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings.

HSD/Designee will audit all resident records for care plan completions. Careplans will be updated on Residents (3,4,5,6) by 4/15/24. Regional Nurse will reeducate ED/HSD/Designee were on creating a comprehensive & accurate care plan to meet resident needs by 4/1/24. ED/HSD/Designee will complete Person Centered Care plans for Dementia and Care Planning in Assisted Living in Relias by 4/15/24. HSD/Designee will review resident evaluations/CP reports weekly to ensure care plans are completed & accurate x4 weeks then quarterly,ongoing. Audit results will be reported to QAPI Director and committee at next scheduled meeting. ED/HSD/Designee were reeducated on evaluation completion on admission, within 30 days, quarterly and with condtion change per regulations by Corporate Director of Policy and Survey on 3/21/24. HSD/Designee will review resident evaluation report from EHR system weekly to ensure completion of evaluations, weekly and ongoing. Results of audits will be reported to QAPI Director and committee at next scheduled meeting

3. Resident 2 was admitted to the facility in 11/2023 with diagnoses including diabetes, cellulitis, and morbid obesity. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 11/07/23, and progress notes, dated 11/10/23 to 03/04/24, were completed. The resident experienced multiple short-term changes without documented monitoring of progress at least weekly until resolution and/or lacked resident-specific directions to staff in the following areas: * 11/14/23 - Pressure ulcer to mid buttock; * 12/05/23 - Pressure ulcer to the coccyx; * 01/02/24 - Two pressure ulcers to the left buttock and one on the right buttock; * 01/18/24 - Right groin skin breakdown; and * 02/05/24 - Skin discoloration to mid-lower back and right shin. The need to ensure short-term changes of condition had documentation to reflect monitoring at least weekly to resolution and provided clear, resident-specific directions to staff was discussed with Staff 2 (Health Services Director) and Staff 3 (RN) on 03/06/24. They acknowledged the findings.  No further information was provided.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents who had short-term or significant changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness, changes were reported to the RN when needed, and progress was documented weekly until resolution for 7 of 7 sampled residents (#s 2, 3, 4, 5, 6, 7, and 8). Resident 4 experienced significant unaddressed agitation and repeated resident-to-resident altercations. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility 11/2023 with diagnoses including dementia with behavioral disturbance and stroke. Observations of the resident, interviews with staff, and review of the resident's record were completed, including the service plan, dated 12/01/23, and temporary service plans, incident reports, outside provider communications, and progress notes dated 12/4/23 through 03/05/24. a. The following changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, progress noted at least weekly through resolution, and/or referral to the nurse for evaluation: * 01/13/24 - Resident-to-resident physical altercation. Resident 4 struck another resident in the arm; * 01/14/24 - Resident-to-resident physical altercation. Resident 4 grabbed another resident by both arms "hard"; * 01/14/24 - Resident-to-resident verbal altercation and attempt to strike a passing resident; * 01/29/24 - Resident-to-resident physical altercation. Resident 4 was striking two different residents who entered his/her room; * 02/02/24 - Resident-to-resident physical altercation. Resident 4 struck another resident who came near his/her room; * 02/06/24 - Resident-to-resident physical altercation. Resident 4 struck two residents who entered his/her apartment and pulled one of the two residents out of their wheelchair and onto the floor; * 02/14/24 - Resident-to-resident physical altercation. Resident 4 found hitting and pushing another resident; * 02/16/24 - Resident-to-resident physical altercation. Resident 4 grabbed and pushed a resident who passed by his/her room; and * 02/25/24 - Resident 4 and another resident were both striking each other. Interventions put in place were to re-direct, keep residents apart, keep apartment door closed, offer snack, fluids, activity, and keep the resident in line-of-sight. Multiple daily observations during day and evening shift between 03/04/24 and 03/06/24, including continuous observations from approximately 1:00 pm to 3:00 pm on 03/04/24 and 7:15 am to 12:00 pm on 03/05/24. The resident was inconsistently in the line-of-sight of staff, was not involved in activities, and was offered food and fluids only at mealtime and some snack times. The resident wandered the halls up and down the unit, going in and out of his/her apartment, the secured courtyard, and the common area bathroom. Two near-altercations were observed; a staff was able to intervene for a dining room incident and a visitor intervened for a hallway incident near Resident 4's apartment. Interviews between 03/04/24 and 03/07/24 showed: Staff 10, 11, 14, and 15 (CGs) and Staff 12 and 17 (MTs) indicated the resident did not like others in his/her personal space or in his/her apartment. The staff stated the resident did not seek out others to start altercations and did not target any specific individuals. The resident would become agitated when others touched him/her or if they attempted to enter his/her apartment. The resident could become aggressive with staff as well when entering apartment and providing care. The staff further indicated the resident was more likely to become agitated if s/he did not understand what you were trying to do. Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated they had no additional information on interventions evaluated or implemented after the resident altercations . Staff 2 stated the resident only became upset when others attempted to enter his/her apartment or if they invaded his/her personal space. Staff 3 had no additional information to provide about the resident's behaviors. Between the dates of 01/14/24 and 02/29/24, the resident experienced multiple short-term changes of condition which were not completely addressed related to effectiveness of interventions and resident-specific information. Additionally, these short term changes were not referred to the facility nurse for evaluation. This resulted in repeated physical altercations with other residents in the facility. b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas: * Emergency room visit; * Medication changes and missed medications; * Swollen ankles; * Choking episodes; and * Resident-to-resident altercations. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and edema. Observations of the resident, interviews with staff, and review of the resident's service plan, dated 12/12/23, and progress notes, dated 11/17/23 to 03/06/24, were completed. The resident experienced multiple short-term changes without documented monitoring of progress at least weekly until resolution, interventions were not reviewed for effectiveness, and/or lacked resident-specific directions to staff in the following areas: * Medication changes and missed medications; * Swollen right hand middle finger; * Multiple bouts of diarrhea; * Skin tears to left arm; * Complaints against roommate; * Injuries to multiple toes on the left foot; and * Increased extremity swelling, shortness of breath, and hospital return. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and the changes of condition were monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. The resident's clinical record, including progress notes and incident reports, dated 12/04/23 through 03/04/24, was reviewed, the resident was observed, and interviews with staff were conducted. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution: * 12/02/23 - Skin tear left forearm; * 12/04/23 - Skin tear to left knee and left elbow;   * 12/09/23 - Unwitnessed fall; * 12/23/23 - Unretractable pain and return from emergency room; * 12/31/23 - Swelling and bleeding of left arm; * 01/11/24 - Skin tears to left arm; * 01/12/24 - Return from emergency room due to arm swelling and high blood pressure; * 01/27/24 - Missed medications; * 02/02/24 - Unwitnessed fall with skin tear to right forearm; * 02/10/24 - Increased confusion; * 02/18/24 - Unwitnessed fall; * 02/22/24 - Return from hospital following head injury and stroke; * 02/23/24 - Admit to hospice and change in medications; * 02/26/24 - Unwitnessed fall; and * 03/03/24 - Trouble swallowing and coughing with meal. The following significant changes of condition lacked documentation that the resident was evaluated, the change was referred to the nurse, and the service plan was updated as needed: * 02/02/24 - Severe weight loss; and * 02/22/24 - Stroke resulting in admittance to hospice and significant increase in care needs. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored through resolution, and the need to ensure there was documentation that significant changes of condition were evaluated, referred to the nurse, and the service plan was updated as needed, was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. The resident's clinical record, including progress notes and incident reports dated 12/04/23 through 03/04/24, were reviewed, the resident was observed, and interviews with staff were conducted. The following short-term changes of condition lacked documentation of actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and/or progress noted at least weekly through resolution: * 12/15/23 - Fall/assist to floor; * 01/10/24 - Injury to left ring finger; * 01/17/24 - Scratches to right and left shoulders; * 01/22/24 - Missed medication; * 01/24/24 - Bruising to left wrist and upper right chest; * 01/26/24 - Redness and bruise to middle of right side of back; * 01/31/24 - Contusion to left hand; * 02/28/24 - Admit to hospice; and * 03/02/24 - Skin tear to left wrist. The need to ensure actions or interventions for short-term changes of condition were documented, communicated to staff on each shift, and monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings. 6.  Resident 7 was admitted to the facility in 10/2021 with diagnoses including dementia. Resident 8 was admitted to the facility in 10/2023 with diagnoses including dementia. The residents' clinical records, including service plans and temporary service plans, were reviewed, the residents were observed, and interviews with staff were conducted. During interviews on 03/04/24 and 03/05/24, Staff stated that Resident 7 and Resident 8 had been engaging in intimate contact for a few weeks. There was no documentation that the residents and their relationship had been evaluated, actions or interventions had been determined and communicated to staff, and monitored at least weekly. The need to ensure short-term changes of condition were evaluated, actions or interventions were documented and communicated to staff on each shift, and were monitored at least weekly through resolution was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings.

Resident #2 no longer resides in community. HSD/Designee/RN Delegation Nurse will evaluate & document all necessary changes & interventions and TSP's in place for residents #3, 4, 5, 6, 7, 8 by 4/1/24. ED/HSD/RN will be reeducated on the need to ensure actions and interventions for short term change in condition were documented and communicated to staff, guidelines for changes of condition and need to ensure all actions& interventions regarding change in condition, and TSP's are completed by the Regional Director of Health Services. HSD/Designee will track on the nursing audit log change of condition weekly to ensure RN change of condition assessment is completed along with service plan updates, by reviewing observation notes and incident reports at least 4 x's/week. The RN took the Role of the Nurse course through Leading Age September 2023. The RN is re-enrolled in this course in May, 2024. Both certificates will be provided to the department. Audit results will be reported to QAPI Director and committee at next scheduled meeting.

3. Resident 2 was admitted to the facility in 11/2023 with diagnoses including diabetes, morbid obesity, osteoporosis, polyarthritis, and congestive heart failure. During the acuity interview on 03/04/24, staff reported the resident needed two-person total assist with all cares and was transferred with two persons and a Hoyer lift. Interviews with staff and Resident 2 and review of the resident's 11/07/23 service plan, temporary service plans, 11/07/23 through 03/04/24  progress notes, hospital visit notes, outside provider visit notes, and incident investigations were completed. The service plan, dated 11/07/23, indicated the resident was ambulatory with a walker and was a one-person assist with transfers and toileting. Resident 2 was observed in bed throughout the survey, with the exception of a two-person Hoyer transfer from the bed to the wheelchair for an out-of-facility appointment. Staff were observed providing two-person full assist with bed mobility, hygiene cares, and dressing. Staff and Resident 2 reported that he/she was able to walk with a walker independently until a fall with a fractured ankle, but was now bed-bound and needed total assist in most ADL cares. Resident 2 reported she ate all meals in her/his bed, needed full assist with all cares, with the exception of being independent brushing hair and teeth with set-up assistance from staff. Resident 2 had multiple significant changes of condition that were not assessed by the RN to include documented findings, resident status, and interventions made as a result of the assessment as follows: * 03/10/24: Fall with ankle fracture. Staff 3 (RN) documented that the resident had fallen and sustained an ankle fracture, although she did not address the significant changes in mobility and ADL assistance needed or develop new interventions as a result; * 11/14/23: Open pressure ulcer to the mid-buttocks. There was no documented  RN assessment which included resident status and interventions made as a result of the assessment. * 01/02/24: Two open areas to the left buttock and one on the right buttock. There was no RN assessment documented of the pressure ulcers which included resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed for all significant changes of condition which included resident status and interventions made as a result of the assessment was discussed with Staff 2 (Health Services Director/LPN) and Staff 3.  Staff 3 acknowledged she had not completed significant change of condition assessments as required.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed in a timely manner which documented findings, resident status, and interventions made as a result of the assessment for 4 of 4 sampled residents (#s 2, 3, 4, and 6) who experienced significant changes of condition. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including dementia with behavioral disturbances and stroke. Progress notes, temporary service plans, and physician communications dated 12/04/23 through 03/05/24 indicated the resident had numerous resident-to-resident altercations between 01/14/24 and 02/25/24. The resident hit, pushed, and grabbed at least four other residents who came too close to him/her, attempted to enter Resident 4's room, or were near his/her apartment. The resident had an additional physical altercation after accidentally entering another resident's apartment. Observations of the resident between 03/04/24 and 03/06/24 showed the resident wandered the halls throughout the day. The resident entered and left his/her apartment several times throughout the day. The resident did not enter other residents' apartments. The resident was observed to grab at other residents on two occasions when the other residents entered his/her personal space. Staff and a visitor were able to intervene before an altercation occurred in both incidents. Interviews with staff between 03/04/24 and 03/07/24, showed the following: Resident 4 was unable to be interviewed. Staff 10, 11, 14, and 15 (CGs) indicated the resident became agitated when others entered his/her personal space or went near the resident's apartment. The staff indicated the resident's behaviors seemed to worsen recently. Staff 11 and 14 stated the resident could sometimes be easily redirected and other times it was more difficult. Staff 10, 11, 14, and 15 further indicated the resident did not target any specific resident or seek out others to have an altercation. The resident was usually calm as s/he walked around the unit. Staff 2 (Health Services Director/LPN) and Staff 27 (RCC) indicated the resident's behaviors did not start until mid-January. Staff 2 stated they sent the resident out for evaluation related to the increased behaviors. Staff 2 stated there was no specific issue found. The staff were not sure what triggered the increase in behaviors and altercations with other residents. The resident did have some medication adjustments over the last month. The staff indicated the medications seemed to help with some of the behaviors. Staff 3 (RN) indicated she was not familiar with all of the resident's behavior issues. She acknowledged the increase in behaviors was significant. Staff 3 stated she did not complete or think about the need for a significant change of condition assessment related to the behaviors. She further indicated she understood the need to address the significant change the resident experienced. No RN assessment could be located for the significant increase in altercations and behaviors. The facility failed to ensure an RN assessment was completed for the resident's increased behaviors which included resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED), Staff 2, Staff 3, and Staff 27 on 03/06/24 and 03/07/24. The staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and edema. Weight records and MARs/TARs, dated 02/19/24 through 02/29/24, and progress notes, hospital discharge notes, and physician communications, dated 11/14/23 through 03/06/24, indicated the following: * The resident had a signed hospital discharge order for daily weights related to congestive heart failure and fluid retention. * A 9.6-pound gain was noted between 02/19/24 and 02/21/24, which constituted a 5.03% significant gain in two days. * A 13.4-pound weight loss was noted between 02/21/24 and 02/22/24, which constituted a 6.73% severe weight loss in one day. * A 16.4 pound weight gain was noted between 02/22/24 and 02/23/24, which constituted an 8.83% severe weight gain in one day. * A 38 pound weight gain was noted between 02/27/24 and 02/28/24, which constituted an 18.4% severe weight gain in one day. * A 38.4 pound weight loss was noted between 02/28/24 and 02/29/24, which constituted a 15.73% weight loss in one day. The resident had an 8.1 pound weight loss between 03/02/24 and 03/02/24 which was not significant. The resident had additional on-going weight losses and gains of 1-4 pounds between 02/01/24 and 03/06/24, which were not considered significant losses or gains. Progress notes, temporary service plans, and physician communications, dated 11/14/23 through 03/06/24, indicated the resident had good intake and ate independently. The resident had ongoing fluid retention due to his/her congestive heart failure that fluctuated. The resident was hospitalized for worsening of his/her congestive heart failure in early January 2024. Observations of the resident between 03/04/24 and 03/06/24 showed s/he spent the majority of his/her time in bed. The resident was observed at meals seated in his/her wheelchair. The resident ate between 50-100% of the four meals observed. The resident declined snacks when offered. The resident carried a lidded water cup with him/her throughout the day for drinking. The resident had compression stockings to both lower legs in place during observations, as well. Interviews with staff and the resident between 03/04/24 and 03/06/24, showed the following: Resident 6 indicated s/he received plenty to eat and drink. S/he stated his/her legs would get swollen off and on, and the doctor was watching it. The resident further indicated s/he had a pacemaker and tried to keep his/her legs up as much as s/he could. Staff 10 and 14 (CGs) and Staff 12 (MT) indicated the resident ate and drank independently, usually at least half of the meal. The staff further indicated the resident had ongoing problems with swelling in his/her extremities. Staff 12 indicated the resident was weighed daily. Staff 3 (RN) indicated she was not aware of the significant weight changes the resident experienced. Staff 3 stated she did not complete a significant change of condition, nor did she think about the need to do so related to daily weights. No RN assessment could be located for the significant weight loss. The facility failed to ensure an RN assessment was completed for the resident's weight losses and gains, including resident status and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3, and Staff 27 (RCC) on 03/06/24 and 03/07/24. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. A review of the resident's clinical record, including the current service plan, dated 12/22/23, progress notes dated 11/09/23 through 01/30/24, and weight records from 09/01/23 through 03/03/24, was completed, and staff were interviewed. The following was identified: a. Review of weight records revealed the following: * 09/2023: 174.5 pounds; * 10/2023: 174.7 pounds; * 11/2023: 176 pounds; * 12/2023: Weight not obtained; * 01/2024: Weight not obtained; and * 02/2024: 123 pounds. The resident experienced a severe weight loss of 53 pounds, or 30.1% in 90 days, between 11/2023 and 02/2024. At the time of survey, on 03/05/24, the resident weighed 155.5 pounds. During an interview on 03/06/24, Staff 3 (RN) stated she was unaware of the resident's weight loss and had not evaluated the resident or completed a significant change of condition assessment. b. The resident was hospitalized on 02/18/24 due to head injury and stroke. Staff stated that prior to hospitalization, the resident ambulated independently with a walker, required no diet modifications or assistance with meals, and was independent with toileting. Upon return from the hospital on 02/22/24, the resident required two-person assistance for all care including toileting and transfers, was unable to ambulate and required staff to assist him/her via wheelchair, had a modified diet texture, and required assistance from staff for meals. There was no documented evidence that the resident was evaluated, a significant change of condition assessment was completed, or that the service plan was updated. Staff 3 stated she was unable to provide any additional information. The need to ensure an RN assessed all significant changes of condition, including findings, resident status, and interventions made as a result of the assessment, in a timely manner was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/07/24. They acknowledged the findings.

Resident #2 no longer resides at community. HSD/Designee/RN will reevaluate resident's #3,4,5 for significant change in condition documented of findings current resident status & interventions by 4/1/24 ED/HSD/RN will b e reeducated on the need to ensure RN assessment is completed which document findings of resident status along with interventions for each resident with significant change of condition & also reeducated on company guidelines as it related to change of condition by Regional Nurse. HSD/Designee will track on the nursing audit log change of condition weekly to ensure RN change of condition assessment is completed along with service plan updates, by reviewing observation notes and incident reports at least 4 x's/week. The RN took the Role of the Nurse course through Leading Age September 2023. The RN is re-enrolled in this course in May, 2024. Both certificates will be provided to the department. Audit results will be reported to QAPI Director and committee at next scheduled meeting. RN to Review monthly weights for loss/gain. Contact physician, family, ensure change of condition is complete and interventions are on the care plan 4/10/2024 RN to Review weekly weights for change of condition follow up through resolution.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care were completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (# 2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task. During the acuity interview on 03/04/24, it was identified that Resident 2 received insulin injections by unlicensed (MT) staff daily.  Review of Resident 2's delegation documentation during the survey revealed the following: The initial delegation reviews for Staff 5 (MT), dated 11/19/23, Staff 7 (MT), dated 02/07/24, and Staff 8 (MT), dated 11/14/23, completed on 03/05/24 lacked the following documentation: * The RN's determination that the client's condition was stable and predictable; * The client did not require assessment during the procedure; * The procedure did not require interpretation or independent decision making; * Results of the procedure were reasonably predictable; * The procedure was not life-threatening and delegation posed minimal risk to the client; * The client's environment supported safe performance of the procedure; and * Documented recommendations on how the client would continue to receive the procedure if the RN was no longer a member of the health care team and the procedure remained ordered for the client. Re-delegation evaluations were reviewed  and revealed the RN did not complete the re-delegation evaluation within 60 days of the initial delegation for Staff 8. In an interview on 03/05/24 at approximately 4:00 pm, Staff 3 (RN) reported being unaware of the current delegation requirements and not knowing the initial re-delegation evaluation must be completed within 60 days of the initial delegation. The need to ensure staff who administered insulin injections were appropriately delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (Health Services Director/LPN) and Staff 3 on 03/05/24. Staff 1 (ED) declined to attend the review of findings. Staff 3 stated she would complete the re-delegation for Staff 8 immediately.  A copy of Division 47 rules was provided.

RN Delegation Nurse re-delegated to staff #8 on 3/5/24. Rn Delegation Nurse will review and update delegation reviews on Staff #5 and #7 by 4/5/24. Regional Director of Health Services reeducated RN Delegation on the requirements of Division 47 as it relates to delegation of staff members on 3/13/24. RN completed the Role of the Nurse course September 12-14, 2023 through Leading Age. The RN is re-enrolled in the course May, 2024. ED/HSD/Designee will audit each delegated staff record to ensure all delegation tasks are documented by 4/1/24 RN will keep delegation paperwork in a binder as required through rule, but will also upload into Staff profile in EHR. Regional Director of Health Services will audit delegation forms weekly x 1 month, every other week x 1 month, and then monthly x 3 months. ED/HSD/Designee will audit delegated staff records monthly to enure all staff is in compliance with Division 47 rules.

Based on interview and record review, it was determined the facility failed to ensure delegation and teaching was provided and documented by an RN in accordance with the Oregon Administrative Rules (OAR) adopted by the Oregon State Board of Nursing (OSBN) in chapter 851, division 047 for 1 of 1 sampled resident (#9) who received subcutaneous injections by a facility unregulated assistive person (UAP). This is a repeat citation. Findings include, but are not limited to: Pursuant to OAR chapter 851, division 006, delegation process means the process utilized by an RN to authorize a UAP to perform a nursing procedure for a client, the outcome of which the RN retains accountability for. The RN must document all delegation process decisions, actions, and outcomes pursuant to OAR 851-045 including comprehensive assessment and reasoned conclusions that identify client problems and risks, educate the UAP, evaluate their learned knowledge, and provide a one-on-one education and evaluation experience with the UAP and the client. During the acuity interview on 07/15/24, Resident 9 was identified to be administered a subcutaneous injection four times daily by a facility UAP. Resident 9's MARs from 06/01/24 through 07/15/24 documented subcutaneous injections had been given by Staff 48 (MT) and Staff 49 (MT). Review of the nursing delegation binder revealed the following: * The binder included documentation of RN delegation and instructions for Staff 48; however, the documentation was not signed by either the RN or Staff 48 and included a sticker stating "need signatures [Staff 48]"; and * The binder included a delegation reauthorization form for Staff 49 that was signed by the RN but did not include the underlying documentation of any initial delegation or instructions. During the phone interview on 07/17/24 at 11:01 am, Witness 2 (Consultant RN) stated she completed the training and assessment over video conference for Staff 48 and relied on facility staff to ensure signatures were obtained. No additional information was provided with respect to Staff 49. The need to ensure nursing delegation and teaching to facility UAPs was provided and documented by an RN in accordance with the OARs adopted by the OSBN in chapter 851, division 047 was reviewed with Staff 1 (ED), Staff 43 (Regional RN) and Staff 17 (LPN) on 07/17/24. They acknowledged the findings.

RN delegator and staff 48 have signed delgation instructions for Resident #9 Staff 49 has been redelegated and all new documentation has been completed and signed. Regional RN/HSD/Designee will audit each delegated staff record to ensure all delegation tasks are documented by 7/31/24

2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including stroke. The resident was not identified during the acuity interview as receiving any outside provider services. Review of the resident's record determined the resident previously received physical therapy and speech therapy services. Observations of the resident, interviews with staff, and review of the service plan, dated 12/01/23, and progress notes and outside provider notes dated 12/04/23 through 03/05/24 were completed. The resident's speech evaluation indicated there would be weekly visits for six weeks related to the resident's diet textures and swallowing concerns. Review of the outside provider notes showed the following: * There was no visit documentation for the week of 01/15/24 and the week of 02/19/24. Under the section "Special Instructions for Residential Staff" the following was noted: * A 01/11/24 visit note indicated speech therapy would work on a communication board to promote efficient communication. * A 01/22/24 visit note indicated the resident should continue mechanical soft textures and add extra moisture and the resident should not use dentures for eating until they fit properly. * A 01/30/24 visit note indicated the staff should use simple, slow speech when communicating with the resident and staff to provide choices and yes/no questions, but only two choices at a time. * A 02/06/24 visit note indicated a recommendation to downgrade textures to minced and moist, continue thin liquids. The resident had difficulty following instructions so minced and moist was the safest option despite resident "shoveling" food in. Interventions attempted to mitigate shoveling were not successful. There was no indication the recommendations were communicated with staff and implemented. The need to ensure on-going coordination of care recommendations were implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure. The resident was identified as receiving outside provider services during the acuity interview on 03/05/24. The resident received physical therapy services. Observations of the resident, interviews with staff, and review of the service plan dated 12/12/23 and progress notes and outside provider notes dated 11/13/23 through 03/06/24 were completed. The resident's signed hospital discharge orders dated 11/10/23 indicated a physical therapy evaluation and treatment referral was ordered. The resident was hospitalized again from 01/04/24 to 01/09/24, and the discharge paperwork indicated upon discharge the resident should resume home health services. Outside provider notes were documented in the resident's record for 11/21/23, 11/22/23, 11/28/23, and 12/5/23. The visits occurred twice weekly. Progress notes reflected physical therapy visits on 11/22/23, 11/27/23, 12/27/23, 02/06/24, and 02/13/24. There were no other outside provider visit notes in the resident's record or provided when requested from staff. The need to ensure on-going coordination of care visits were documented in the resident's record and any recommendations were implemented was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure information and interventions provided by outside service providers were communicated to staff and service plans adjusted if necessary for 3 of 5 sampled residents (#s 2, 4, and 6) who received outside services. Findings include, but are not limited to: 1. Resident 2's current service plan, temporary service plans, progress notes, 02/01/24 through 03/04/24 MARs/TARs, and outside provider visit notes dated 12/04/23 through 03/04/24 were reviewed. The following outside provider recommendations were noted: * 12/27/23 - "Please turn pt [patient] every two hours to prevent bed sore"; * 01/02/24 - "Continue to turn and reposition patient at least every two hours and with incontinence episodes"; * 01/09/24 - "Encourage protein intake as able for wound healing"; * 01/25/24 - "Change bandage to right buttock when wet/soiled or every other day";                   * 02/02/24 - "Ok to replace foam dressing if falls off or wet/soiled"; and * 02/19/24 - "Recommend position changes every two to four hours to reduce pressure to area." There was no documented evidence the recommendations were implemented with updates to the service plan and MARs/TARs or evidence that staff were informed. The need to ensure the facility had protocols to ensure staff were informed of outside provider information and interventions, and the service plan adjusted if necessary, was reviewed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/06/24. They acknowledged the findings.

ED/HSD were reeducated on the need to have an effective a system was place to ensure staff were informed of outside provider information & recommended interventions,coordination of care & the service plan adjusted as needed on 3/21/24 (Completed verbally by Corporate Compliance Nurse ). HSD/Designee will f/u with outside providers to ensure all recommendations are followed up on and if they are still recommended, by 4/1/24. HSD/Designee to ensure provider notes are entered into EHR and recommendations are followed up on. HSD/Designee will review outside provider notes at least 3 x's/week for follow up. HSD/Designee will check at least 3 x's/week for outside provider communication form &visit notes x30 days, then weekly. All Audit Results will be reported to the QAPI Director & Committee at next scheduled meeting.

Based on interview and record review, it was determined the facility failed to ensure it had a trained and designated Infection Control Specialist and failed to develop protocols to prevent the development and transmission of communicable diseases. Findings include, but are not limited to: In an interview on 03/05/24 with Staff 1 (ED), he reported the facility did not have an Infection Control Specialist. On 03/07/24, Staff 1 was requested to provide the facility's infection prevention and control protocols. Staff 1 reported they did not have that information on site. The need to have a trained and designated Infection Control Specialist and to have protocols in place to prevent the development and transmission of communicable diseases was discussed with Staff 1 (ED) on 03/07/24. He acknowledged the findings. Infection prevention and control protocols were provided prior to survey exit.

ED completedf course on 3/25/24. ED/HSD were reeducated on requirements & company guidelines to have a designated IC Specialist & ensure infection control protocols are place on 3/21/24 per Corporate Director of Policy & Survey. ED/HSD were provided guidelines for OR state IC Specialist by Regional Nurse on 3/21/24. ED/HSD will complete online Infection Control Training per Oregon Care Partners

Based on interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to: During the change of ownership survey, conducted 03/04/24 through 03/07/24, administrative oversight of the facility's medication system was found to be ineffective based on deficiencies in the following areas: * C282 - RN Delegation and Teaching; * C303 - Systems: Medication and Treatment Orders; * C304 - Systems: Medication and Treatment Review; * C310 - Systems: Medication Administration; * C315 - Systems: Treatment Administration; and * C330 - Systems: Psychotropic Medication. The need to ensure a safe medication system and to ensure adequate professional oversight was discussed with Staff 1 (ED) on 03/07/24. He acknowledged the findings.

Weekly medication cart audit will be completed on Wednesday and the HSD/ED/Designee will order any medications that are 7-14 days from running out and not on cycle fill. The ED/HSD/Designee will run the medication exception report at least 3 x's/week and follow up on any refusal of medications that Physician notification occurred. If it did not occur, the Med tech will be re- educated and the ED/HSD/Designee will notify the physician. The HSD/Designee will complete an audit of medication orders initially, and then monthly to ensure the correct diagnosis and reason for use is outlined on the MAR. The HSD/Designee will complete an audit of physician orders for non-pharmacological interventions listed. RN/HSD/Designee will audit progress notes and PRN administration records at least 3x's/weekly x 2 months, 2 x's weekly x 1 month, and then weekly for documentation related to non-pharmacological interventions. ED/HSD/Designee will provide continuous training for med techs by holding a training meeting every quarter to review relevant topics. First meeting will be held by 5/5/24.

2. Resident 4 was admitted to the facility in 11/2023 with diagnoses including stroke. The resident's 12/04/23 through 03/05/24 progress notes and physician communications, 02/28/24 signed physician orders, and the 02/01/24 through 03/06/24 MARs/TARs were reviewed. The 02/01/24 through 03/06/24 MARs/TARs showed the following: * An order for Divalproex (anticonvulsant medication) twice a day. The medication was documented as unavailable on 44 occasions between 02/01/24 and 03/06/24. During this same time period the medication was documented as administered on 20 occasions interspersed between multiple days marked as unavailable. * An order for furosemide (diuretic to decrease excess fluid) to be given daily. The medication was documented as unavailable on 27 occasions between 02/01/24 and 03/06/24. During this same time period the medication was documented as administered on six occasions interspersed between multiple days marked as unavailable. The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. Staff 2 and 3 were unsure why the medication was signed as administered when other doses indicated unavailable. The staff acknowledged the findings. 3. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and edema. The resident's 11/17/23 through 03/06/24 progress notes and physician communications, 01/09/24 signed hospital discharge orders, 02/26/24 signed physician orders, and the 02/01/24 through 03/06/24 MARs/TARs were reviewed. a. The 02/01/24 through 03/06/24 MARs/TARs showed the following: * An order for Folbee (vitamin supplement) to be given daily. The medication was documented as unavailable on 25 occasions between 02/01/24 and 03/06/24. During this same time period the medication was documented as administered on 10 occasions interspersed between multiple days marked as unavailable. * An order for Senna (bowel medication) to be given daily. The medication was documented as unavailable on 25 occasions between 02/01/24 and 03/06/24. During this same time period the medication was documented as administered on 10 occasions interspersed between multiple days marked as unavailable. * An order for Vitamin B-1 (vitamin supplement) to be given daily. The medication was documented as unavailable on 20 occasions between 02/01/24 and 03/06/24. During this same time period the medication was documented as administered on 15 occasions interspersed between multiple days marked as unavailable. In interviews on 03/06/24, Staff 2 (Health Services Director/LPN) and Staff 3 (RN) indicated they were unsure why staff documented the medications were unavailable on some days and signed the medication as administered on other days. b. "Heart Failure Discharge Instructions," included with the resident's 01/09/24 discharge orders, indicated to record weights daily and report to the physician if a gain of 2-3 pounds in 24 hours or if a gain of five pounds or more in one week. The 02/01/24 through 03/06/24 MARs/TARs and weight records showed the following: * No weights were documented from 02/01/24 to 02/13/24 due to resident refusals; * A 9.6-pound increase was noted from 02/19/24 to 02/21/24; * A 16.4-pound increase was noted from 02/21/24 to 02/22/24; * A 3.4-pound increase was noted from 02/23/24 to 02/24/24; and * A 38-pound increase was noted from 02/27/24 to 02/28/24. There was no documentation the physician was notified of the increases in the resident's weight. The need to ensure the facility administered all medications and treatments as ordered by the physician was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. Staff 2 and 3 were unaware of any parameters around the resident's daily weights or hospital discharge instructions. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to follow physician or other legally recognized practitioner orders as prescribed and/or failed to have written, signed orders in the resident's facility record for all medications and treatments the facility was responsible to administer for 3 of 5 sampled residents (#s 2, 4, and 6) whose physician orders were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including insulin-dependent diabetes, hypertension, congestive heart failure, and polyarthritis. During the acuity interview on 03/04/24, the resident was identified as being administered insulin multiple times daily by facility staff. The resident's 02/01/24 through 03/04/24 MARs and 11/07/23 through 03/04/24 progress notes were reviewed, along with physician orders and communications. The following was identified: a. There were no signed physician or other legally recognized practitioner orders for the following medications being administered: * Acetaminophen 1000 mg three times a day (used for pain and/or fever); * Allopurinol 100 mg once a day at waking (used for gout); * Atrovastatin 40 mg at bedtime (used to lower cholesterol); * Calcium Carb W/D3 600 mg/400 IU one by mouth daily at lunch for supplementation; * Docusate Sodium 100 mg softgel twice daily (used for bowel function); * Eliquis 5 mg twice daily at waking and at bedtime for anticoagulation; * Ezetimibe 10 mg once daily at waking (used to lower cholesterol); * Ferrous Sulfate 325 mg at bedtime for supplementation; and * Gabapentin 300 mg twice daily for nerve pain. b. There was no documented evidence the resident received medications as ordered for the following: * On 11/8/23 at 7:53 pm Staff 7 (MT) documented in the progress notes that the resident "did miss CBG checks and insulin today as we were waiting delegation from the nurse." * On 11/15/23 at 1:19 pm Staff 40 (RCC) documented in the progress notes that "resident did not get [his/her] insulin today because I am not delegated. There was nobody here delegated either that could have done it." * Insulin Aspart 100 unit/ml pen was ordered to be administered based on Resident 2's blood glucose level (CBG) at 08:00 am, 12:00 pm and 05:00 pm daily as follows: six units for CBG 141-180, eight units for CBG 181-220, etc. There were four occasions between 02/1/24 and 02/29/24 where the documentation indicated sliding scale insulin was administered when the resident's CBG was below 141, indicating no sliding scale insulin should have been administered. The need to ensure all medications the facility administered had signed physician or other legally recognized practitioner orders and that medications were administered as ordered was discussed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/16/24. No further documentation was provided.  They acknowledged the findings.

Resident #2 was sent to the hospital on 3/14 and never returned. She moved out of the community on 3/21. Orders requested multiple times starting on 3/7 by med staff. The HSD/ED/Designee will ensure that signed and dated physician orders are received for a resident 24 hours prior to move in. The HSD/ED/Designee will print all physician orders quarterly for signature and send to pharmacy to ensure they are accurate. Resident #4 and #6 -Medication records were reviewed and medication carts audited for missing meds on 3/28/24. Incident reports for medication variances were completed on , physician and POA's notified. Weekly medication cart audit will be completed on Wednesday and the HSD/ED/Designee will order any medications that are 7-14 days from running out and not on cycle fill. HSD/Designee will reeducate medication staff on medication variances per company guidelines, appropriate notifications to pharmacy and the use of the back up pharmacy when meds are not avalabile by 4/15/24.

Based on interview and record review, it was determined the facility failed to ensure a registered pharmacist or registered nurse reviewed all medications and treatments administered by the facility to a resident at least every 90 days. Findings include, but are not limited to: In an interview on 03/07/24, at approximately 10:15 am, Staff 2 (Health Services Director/LPN) reported a registered pharmacist or registered nurse had not reviewed all medications and treatments administered by the facility to residents in the last 90 days. The need to ensure all medications and treatments administered by the facility were reviewed by a registered pharmacist or RN at least every 90 days was discussed with Staff 1 (ED) at approximately 10:25 am on 03/07/24. He acknowledged the findings.

ED/HSD were reeducated on ensuring Pharmacy Consultant visits were completed every 90 days and recommendations followed up on 3/21/24 by the Regional Director of Health Services. Pharmacist review was performed in December, 2023. HSD/Designee will follow up with recommendations from this audit by 4/10/2024. HSD/Designee will ensure recommendations are sent to primary care physicians quarterly when received from the pharmacy. Pharmacy will complete a total MAR-cart audit and findings will be followed up on by HSD/RN.

3. Resident 2 was admitted to the facility in 11/2023 with diagnoses including congestive heart failure and insulin-dependent diabetes. The resident's 11/07/23 through 03/04/24 progress notes and physician communications, 02/17/24 signed physician orders, and the 02/01/24 through 03/04/24 MARs were reviewed. The 02/01/24 through 03/04/24 MARs showed 17 of the resident's prescribed medications had no reason for use. The need to ensure medication administration records were complete was discussed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/06/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for 5 of 5 sampled residents (#s 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 11/2023 with diagnoses including stroke. The resident's 12/04/23 through 03/05/24 progress notes and physician communications, 02/28/24 signed physician orders, and the 02/01/24 through 03/06/24 MARs/TARs were reviewed. The 02/01/24 through 03/06/24 MARs/TARs showed there was no reason for use documented for any of the resident's medications. The need to ensure medication administration records were complete was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings. 2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and edema. The resident's 11/17/23 through 03/06/24 progress notes and physician communications, 01/09/24 signed hospital discharge orders, 02/26/24 signed physician orders, and the 02/01/24 through 03/06/24 MARs/TARs were reviewed. The 02/01/24 through 03/06/24 MARs/TARs showed nine of the resident's prescribed medications had no reason for use. The need to ensure medication administration records were complete was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings. 4. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. The resident's 12/03/23 through 03/04/24 progress notes and physician communications, signed physician orders, and the 02/01/24 through 03/04/24 MARs/TARs were reviewed. The following was identified: * Omeprazole 40 mg (for reflux) was noted as administered on 02/27/24; all other dates 02/24/24 through 03/04/24 stated medication was not provided as it had not yet been delivered; * Hydromorphone 1 mg/ml solution (for pain not relieved by all other pain medications) was noted as administered on 02/28/24 without documentation of other pain medications given for pain prior to administration; and * PRN pain medications acetaminophen 650 mg and tramadol 50 mg lacked resident-specific parameters for administration. The need to ensure medication administration records were complete was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) 03/07/24. They acknowledged the findings. 5. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. The resident's 12/03/23 through 03/04/24 progress notes and physician communications, signed physician orders, and the 02/01/24 through 03/04/24 MARs/TARs were reviewed. The following was identified: * PRN medications for nausea, lorazepam 0.5 mg and prochlorperazine 10 mg, lacked resident-specific parameters for administration; and * March MAR/TAR contained four medication and/or treatment orders which were still active, although they had been discontinued on 02/27/24. The need to ensure medication administration records were complete was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) 03/07/24. They acknowledged the findings.

The EMAR will be updated by the HSD and RCC to include all missing information for Res #3,4,5,6. Residen #2 no longer resides in the community. HSD/Designee will complete an audit of all medication orders by 4/15/2024 to ensure that: There is a diagnosis/reason for use on the MAR; PRN Psychotropic Medications have non- pharmacological interventions listed; and any resident specific parameters are on the MAR. This audit will then be done weekly x 1 month, and then monthly. HSD/Designee will monitor observation notes 3 x 's/week x 4 weeks, 2 x's/week x 4 weeks and then weekly for documented non-pharmacological interventions prior to administration of a PRN psychotropic medication. Med techs will be educated by the HSD/RN to include training on the importance of documenting effectiveness of PRN medications,the use and documentation of non-pharmacological interventions before giving PRN psychotropic medications and the requirement to ensure every medication order approved has a documented reason for use.

2. Resident 6 was admitted to the facility in 10/2023 with diagnoses including congestive heart failure and edema. The resident's 11/17/23 through 03/06/24 progress notes, physician communications, and temporary service plans, 02/26/24 signed physician orders, and the 02/01/24 through 03/06/24 MARs/TARs were reviewed. A standing order for "minor skin tear"was noted on the resident's MARs/TARs. Progress notes revealed ongoing treatments to multiple skin tears obtained since 02/01/24. The facility staff failed to document any of the treatments administered on the resident's treatment administration record. The need to ensure all treatments administered by the facility were documented on the treatment administration record was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to keep an accurate treatment record of all treatments ordered by a legally-recognized practitioner and administered by the facility, for 2 of 4 sampled residents (#s 2 and 6) whose records were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 11/2023 with diagnoses including congestive heart failure, cellulitis, and diabetes. The resident's 11/17/23 through 03/04/24 progress notes, physician communications, and temporary service plans, physician orders signed 02/26/24, outside provider visit notes, and the 02/01/24 through 03/04/24 MARs/TARs were reviewed. The RN outside provider visit notes included directions to staff to change the dressing to the right and/or left buttock with a foam dressing if it became wet or soiled on multiple dates. On 03/05/24 the resident was observed during cares to have a foam dressing in place. On 03/06/24 Staff 28 (RCC) was interviewed and reported that staff were changing the dressing on the resident's buttocks one to two times daily. The facility staff failed to document any of the treatments administered on the resident's treatment administration record. The need to ensure all treatments administered by the facility were documented on the treatment administration record was discussed with Staff 2 (Health Services Director/LPN) and Staff 3 (RN) on 03/06/24. The staff acknowledged the findings.

Resident #2 no longer resides at community. The HSD/RN will evaluate the need for on-going treatment orders for Res #6. HSD/Designee will audit all resident's treatment records for accuracy and make any changes needed. HSD/Designee will conduct a clinical staff training by 4/15/24 to include guidelines for skin care and the importance of documenting all treatments on TAR's . HSD/RN/Designee will audit all treatment orders for accuracy by 4/20/2024 and then at least monthly. HSD/RN/Designee will educate all med staff on documentation expectations.

3. Resident 4 was admitted to the facility in 11/2023 with diagnoses including stroke. The resident's 12/04/23 through 03/05/24 progress notes and physician communications, 02/28/24 signed physician orders, and the 02/01/24 through 03/06/24 MAR/TARs were reviewed. The 02/01/24 through 03/06/24 MAR/TARs showed the following: * Olanzapine, 5 mg every six hours PRN agitation. The medication had not been administered to the resident. The MARs did not contain resident-specific parameters for staff describing how the resident expressed agitation. Additionally, there was no documentation of what non-drug interventions staff were to attempt prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed agitation and non-drug interventions to attempt and document prior to administration of the medication was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), and Staff 3 (RN) on 03/07/24. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medication used to treat resident behaviors had written, resident-specific parameters and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication for 3 of 3 sampled residents (#s 3, 4, and 5). Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 06/2022 with diagnoses including dementia. Review of the resident's 02/01/24 through 03/04/24 MAR and current physician orders revealed the following: * An order for lorazepam 0.5 mg, one tablet to be administered every 4 hours as needed for anxiety, agitation, restlessness and/or nausea; and * The medication was administered four times. The MAR lacked resident-specific parameters for staff describing how the resident presented behaviors such as agitation. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator/LPN) on 03/07/24. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2015 with diagnoses including dementia. Review of the resident's 02/01/24 through 03/04/24 MARs and current physician orders revealed the following: * An order for lorazepam 0.5 mg, one tablet to be administered every 4 hours as needed for anxiety/agitation/restlessness/nausea; and * The medication had not yet been administered to the resident. The MARs lacked resident-specific parameters for staff describing how the resident presented behaviors such as agitation. There was no documentation of what non-pharmacological interventions were to be attempted prior to administration of the medication. The need to ensure there were resident-specific descriptions of how the resident behaviors presented, and non-pharmacological interventions were attempted and documented as not effective prior to administration of the medication, was discussed with Staff 1 (ED) and Staff 2 (Health Services Administrator/LPN) on 03/07/24. They acknowledged the findings.

HSD/Designee will add individualized interventions to PRN psychotropic medications and resident specific parameters for Res 3,4,&5 by 4/15/24. ED/HSD/Designee will reeducate all med techs/staff on using non-pharmcological interventions and documenting the use of all non-pharmcological interventions prior to administration of psychotropics. HSD/Designee will audit all PRN psychotropic medications ordered to ensure accuracy, and that each prn psychotropic has listed resident specific non-pharmacological interventions that staff are to attempt prior to the administration.

Based on observation, interview, and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: In the acuity interview on 03/05/24, there were residents identified for each of the four buildings on campus who required the assistance of two staff for transfers. As part of reviewing the facility's acuity-based staffing tool (ABST), staffing plans for the four resident-occupied buildings on the campus were observed on 03/06/24 at 8:40 am. The posted staffing plans indicated the following: * Buildings 910, 920, and 950:   - Day Shift - 1 MT, 2 CG;   - Evening Shift - 1 MT, 2 CG; and   - Overnight Shift - 1 MT, 1 CG. * Building 940:   - Day Shift - 1 MT, 2 CG;   - Evening Shift - 1 MT, 2 CG; and   - Overnight Shift - 0.5 MT, 1 CG. On 03/06/24 at 9:35 am, Staff 2 (Health Services Director/LPN) reported a caregiver was scheduled to work in each of the four buildings every night. In addition, on five nights a week there were two MTs on duty to cover all four buildings, and on two nights a week there was one MT on duty to cover all four buildings. The need to have a sufficient number of staff in each building to meet all scheduled and unscheduled needs of residents on the overnight shift was discussed with Staff 1 (ED) and Staff 18 (Business Office Manager) on 03/06/24. They acknowledged the findings.

ED/HSD will be re-educated on the ABST staffing tool and expectations by the Regional Director of Operations and the Regional Director of Health Services. HSD/ED/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED/Designee will audit 10% of resident evaluations/service plans per month to ensure accuracy of services provided and time of care provided. ED/Designee will ensure that staffing meets or exceeds the ABST tool to meet resident's scheduled and unscheduled needs.

Based on interview and record review, it was determined the facility failed to update the acuity-based staffing tool (ABST) whenever a resident experienced a significant change of condition and/or no less than quarterly and failed to staff to the level indicated on their posted staffing plan. Findings include, but are not limited to: The facility was using the Oregon Department of Human Services' ABST, which was reviewed on 03/05/24. The following was identified: * Data for multiple residents had not been updated within the last 90 days; and * The facility was not staffing the overnight shift to the level indicated by the staffing plan posted in each building. The need to update the ABST before a resident moved into the facility, with amendments as appropriate within the first 30 days, whenever a resident experienced a significant change of condition, and/or no less than quarterly, preferably at the same time the residents' service plans were updated, and the need to staff to the level indicated by the posted staffing plans was discussed with Staff 1 (ED) on 03/05/24. He acknowledged the findings.

ED/HSD will be re-educated on the ABST staffing tool and expectations by the Regional Director of Operations and the Regional Director of Health Services. HSD/ED/Designee will update the ABST tool prior to a resident moving in, with quarterly service plan updates and with any change of condition. ED/Designee will audit 10% of resident evaluations/service plans per month to ensure accuracy of services provided and time of care provided. ED/Designee will ensure that staffing meets or exceeds the ABST tool to meet resident's scheduled and unscheduled needs

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly hired staff (#s 13, 15, 16, and 17) completed and documented training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/05/24. There was no documented evidence Staff 13 (MT), Staff 15 (CG), Staff 16 (CG), or Staff 17 (MT), hired 01/11/24, 01/04/24, 12/07/23, and 02/01/24, respectively, completed training in First Aid and abdominal thrust within 30 days of hire. The need for staff to complete all required training within the specified time frames was discussed with Staff 1 (ED) and Staff 18 (Business Office Manager) on 03/06/24. They acknowledged the findings.

The BOM/Designee will conduct a full Employee File audit. The ED/BOM will schedule any missing training for all current staff to complete by 4/30/2024. Orientation checklists will be provided to all staff upon hire by the BOM. The BOM will track that these are completed within 3 working days and that the HSD/ED/designee has signed off, and will place in employee files and upload into ALIS under the staff profile. The BOM/Designee will track new hire and annual training requirements utilizing the CBC worksheet and ensure they are completed. The BOM/designee will audit 10% of emplyee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month on alternating shifts, with all required elements documented, and failed to provide fire and life safety training to staff on alternate months, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/05/24. 1. There was no documented evidence fire drills were conducted on alternating months on all shifts. The following required elements were not documented: * Location of simulated fire origin; * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Number of occupants evacuated. In addition, there was no documented evidence alternate routes were used during fire drills. 2. There was no documented evidence fire and life safety instruction was provided to staff on alternating months from fire drills. The need to conduct fire drills every other month and document all required elements and provide fire and life safety training to staff on alternating months was discussed with Staff 1 (ED) on 03/05/24. He acknowledged the findings.

All managers will be trained by the VP Environmental Services on the rules and policy on fire drills by 4/15/2024. The MTD/ED/Designee will conduct fire drills per policy each month on varying shifts so that each shift has one per quarter. All managers will be trained by the VP Environmental Services on the required training every other month by 4/15/2024. Fire drills and education will be logged in the TELS system by the MTD/ED/Designee. Fire drills and every other month education will be discussed monthly at the CQM meeting. The ED/Designee will audit TELS monthly for completion.

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission; and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 03/05/24. In an interview on 03/05/24 at approximately 12:35 pm, Staff 1 (ED) reported residents have not been receiving fire and life safety training on admission, nor has the facility been re-instructing residents at least annually. The need to instruct and re-instruct residents on fire and life safety training per the OFC requirements was discussed with Staff 1 (ED) on 03/05/24. He acknowledged the findings.

All managers will be trained by the VP Environmental Services on the requirement for initial and annual required training for fire safety by 4/15/2024. This training will be scheduled in the TELS system for an annual date.

Based on observation and interview, it was determined the facility failed to ensure facility grounds were kept free of refuse and all exterior pathways and accesses to the RCF common use areas were maintained in good repair. Findings include, but are not limited to: On 03/04/24, outdoor areas of the 910, 920, 940, and 950 cottages were toured, and the following was identified: * The 910, 920, 940, and the 950 cottage courtyards contained multiple drop-offs, ranging from one to two inches from the concrete to the planting bed. The drop-offs created a potential fall hazard for residents who used the courtyard; * A section of concrete sidewalk between the 920 and 940 cottages was uneven and in need of repair. The uneven sidewalk created a potential fall hazard for residents who used the courtyard; and * The 940 and 950 cottages courtyards contained large piles of leaves and refuse near fence lines. On 03/06/24, an environment tour was conducted via telephone with Staff 1 (ED). He acknowledged the findings.

We will coordinate with our internal Maintenance Director and/or Landscape Vendor to address all the ground areas adjacent to the sidewalk that are not flush, filling the areas to alleviate potential fall hazards in all courtyards by 4/15/2024. We will coordinate with a concrete vendor to have the uneven section of sidewalk between cottage 920 and 940 to be repaired by 4/19/2024 We will coordinate with our internal Maintenance Director and/or Landscape Vendor to address the leaves and debris in the courtyards of 940 and 950 Cottages and the fence line by 4/15/2024 . ED/MTD/Designee will perform a monthly environmental walk through using the CBC form for ongoing compliance.

Based on observation and interview, it was determined the facility failed to ensure all exterior pathways and accesses to the RCF common-use areas were maintained in good repair. This is a repeat citation. Findings include, but are not limited to: On 07/15/24 at 11:05 am, outdoor grounds of the 910, 920, 940, and 950 cottages were toured, and the following was identified: The outdoor courtyard areas of all four cottages contained multiple drop-offs, of at least two inches from the concrete walkway to the planting bed. The 910 cottage contained a patio area, accessed from the common-use dining room, which had drop-offs of three to four inches around the concrete surface. These drop-offs created a potential fall hazard for residents who used the courtyard areas. On 07/16/24, at approximately 10:30 am, the outdoor grounds were toured with Staff 45 (Maintenance Director). He acknowledged the findings and stated plans to build up the drop-off areas to meet regulations. On 07/17/24, the need to maintain exterior pathways in good repair was discussed with Staff 1 (ED). He acknowledged the findings.

ED met with Landscape Contractor to come up with more permanent solution to the drop offs from the sidewalks. We are installing a base of pea gravel and then covering it with bark dust to create a more stable solution. ED to continue monthly enviornmental walk through with MTD.

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: On 03/04/24, the interiors of the 910, 920, 940, and 950 cottages were toured, and the following areas were identified to be in need of cleaning and/or repair: -Building 910: * Family room chairs were stained. -Building 920: * Room 4's carpet was stained; * Common area floors had gouges and scrapes; and * Multiple walls, doors, and door frames throughout had scuffs and scrapes. -Building 940: * Multiple walls, doors, and door frames throughout had scuffs and scrapes; * Room 3 had non-resident furniture overflowing into resident area;   * Room 5's carpet was significantly stained and had an odor which did not dissipate during three days of survey; * Room 6 had a broken toilet seat; and * Room 10 had extensive paint splatter on the floor and baseboards. -Building 950: * Room 9's door failed to seal when shut, allowing others to view into the room; * Common area floors had gouges and scrapes; and * Multiple walls, doors, and door frames throughout had scuffs and scrapes. On 03/06/24, an environment tour was conducted via telephone with Staff 1 (ED). He acknowledged the findings.

We will coordinate with the Maintenance Director on site, as well as engage professional Carpet Cleaning and/or Painting services as needed to address the cleanliness and repairs of all items not in compliance as listed by cottage by 4/30/2024. ED/MTD/Designee will perform a monthly environmental walk through using the CBC form for ongoing compliance.

2. During the survey, observations were made of the emergency call system in buildings 910, 920, 940, and 950, and staff were interviewed. Staff reported that resident units were equipped with emergency pull cords which, when pulled, alerted to a staff phone. Upon testing the system, surveyors found that the call system did not alert to the staff phone for multiple resident units throughout buildings 910, 920, and 940. Staff indicated the call system did not reliably alert them when residents attempted to use it. During an interview on 03/07/24, Staff 1 (ED) stated he was not aware the call system was not consistently working in resident units. He stated he would immediately audit and begin fixing the call system. The need to ensure the facility provided a call system that connected resident units to the care staff center or staff pagers was reviewed with Staff 1 (ED) on 03/06/24. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure exit doors were equipped with an alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: 1. Observations on 03/04/24 revealed exit doors to the interior courtyards of the 940 and 950 memory care units and the front doors of the 910 and 920 cottages failed to have an alarm or other acceptable system to alert staff when residents exited the building. On 03/06/24, the need to ensure exit doors were equipped with an audible alarm or other acceptable system was discussed with Staff 1 (ED). He acknowledged the findings.

Corporate MTD/VP Environmental Operations/ED will audit the Existing Door Alarms and Nurse Call System throughout all cottages and the effective communication to alert staff with pagers and/or alarms to ensure the system is in compliance and address. The ED/MTD/Designee will perform a weekly test on the call system, door alarms, and gates.

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 C150, C160, C200, C231, C242, C360, C361, C372, C420, C422, C510, C513, and C555.

Refer to C150, C160, C200, C231, C242, C360, C361, C372, C420, C422, C510, C513, and C555.

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 510

Refer to C510

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired staff (#s 13, 15, and 16) completed all required pre-service orientation and dementia training within the required time frames; failed to ensure 4 of 4 newly hired staff (#s 13, 15, 16, and 17) demonstrated competency in all assigned job duties within 30 days of hire; and failed to ensure 4 of 4 long-term employees completed the required number of annual in-service training hours, including infectious disease prevention and six hours of dementia training. Findings include, but are not limited to: Staff training records were reviewed on 03/05/24. a. There was no documented evidence Staff 13 (MT), Staff 15 (CG), and Staff 16 (CG), hired 01/11/23, 01/04/24, and 12/07/23, respectively, completed one or more of the following pre-service orientation elements: * Resident rights and values of CBC care; * Infectious Disease Prevention; * Fire safety and emergency procedures; and * Written job description. b. There was no documented evidence Staff 13 (MT), Staff 15 (CG), and Staff 16 (CG), hired 01/11/23, 01/04/24, and 12/07/23, respectively, completed one or more of the following pre-service dementia training topics: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Environmental Factors that are important to a resident's well-being (e.g., staff interactions, lighting, room temperature, noise, etc.); * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require ongoing assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in memory care communities. c. There was no documented evidence Staff 13 (MT), Staff 15 (CG), Staff 16 (CG), or Staff 17 (MT), hired 01/11/24, 01/04/24, 12/07/23, and 02/01/24, respectively, demonstrated competency in all assigned job duties, including the following: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation; * Other duties as applicable (Med pass, treatments); and * First Aid/Abdominal Thrust. On 03/05/24, at approximately 3:05 pm, Staff 1 (ED) and Staff 18 (Business Office Manager) were informed all MTs must demonstrate competency in their assigned job duties before they could pass medications again, including those on duty at the time. At approximately 4:30 pm, Staff 2 (Health Services Director/LPN) reported she would be completing competency checklists with staff on duty at the time, as well as the Resident Care Coordinators (RCCs). She stated the RCCs would be observing competency of MTs on the overnight shift of 03/05/24 and before the first med pass on day shift on 03/06/24. Copies of completed medication technician competencies for nine MTs and two RCCs were received on 03/06/24. d. There was no documented evidence Staff 8 (MT/CG), Staff 19 (CG), Staff 20 (CG), or Staff 21 (Receptionist), hired 12/23/03, 08/16/04, 07/26/10, and 07/25/08, respectively, had completed the required annual infectious disease prevention training. e. There was no documented evidence Staff 8, Staff 19, or Staff 20 completed the required number of annual in-service training hours, including at least six hours of dementia care topics. The need to ensure all staff complete required training in the specific timeframes required by rules was discussed with Staff 18 (Business Office Manager) on 03/05/24 and Staff 1 (ED) and Staff 18 on 03/06/24. They acknowledged the findings.

The BOM/Designee will conduct a full Employee File audit. The ED/BOM will schedule any missing training for all current staff to complete by 4/30/2024. Orientation checklists will be provided to all staff upon hire by the BOM. The BOM will track that these are completed within 3 working days and that the HSD/ED/designee has signed off, and will place in employee files and upload into ALIS under the staff profile. The BOM/Designee will track new hire and annual training requirements utilizing the CBC worksheet and ensure they are completed. The BOM/designee will audit 10% of emplyee files weekly x 2 months, bi-weekly x 2 months, and then monthly to maintain compliance.

Based on observation, interview, and record review, it was determined the facility failed to follow health care rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C252, C260, C270, C280, C282, C290, C295, C300, C303, C304, C310, C315, and C330.

Refer to C252, C260, C270, C280, C282, C290, C295, C300, C303, C304, C310, C315, and C330.

Based on 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. This is a repeat citation. Findings include, but are not limited to: Refer to C 282

Refer to C282

Based on observation, 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 4 of 4 sampled residents (#s 3, 4, 5, and 6). Findings include, but are not limited to: Resident 3, 4, 5, and 6's service plans were reviewed. 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 needs and preferences was discussed with Staff 1 (ED) and Staff 2 (Health Services Director/LPN) on 03/06/24 and 03/07/24. They acknowledged the findings.

Service plans for Res 3,4,5,6 will be updated to include individualized information for nutrition and hydration needs will be completed by 4/15/24. HSD/Designee will audit all resident records to ensure all individual hydration and nutrition needs are care planned by 5/1/24. Regional Nurse will reeducate ED/HSD/Designee on creating a comprehensive & accurate care plan to meet resident needs by 4/1/24. ED/HSD/Designee will complete Person Centered Care plans for Dementia and Care Planning in Assisted Living in Relias by 4/15/24. HSD/Designee will review resident evaluations/CP reports weekly to ensure care plans are completed & accurate x4 weeks then quarterly ongoing. Audit results will be reported to QAPI Director and committee at next scheduled meeting.

Based on observation, interview, and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the residents and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 5 of 6 sampled residents (#s 3, 4, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: Residents 3, 4, 5, and 6's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents' individual activity needs in one or more of the following areas: * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and/or * Activities that could be used as behavioral interventions, if necessary. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist the resident with more individualized activities. Observations between 03/04/24 and 03/06/24 showed minimal to no group activities being led by facility staff within the individual houses. Intermittent large group activities were conducted in other areas of the campus and individual residents were invited from the four houses. Residents located in the houses were observed wandering the halls, sleeping in chairs, or seated in the common area with a movie or music playing. The need to ensure all residents had individualized activity plans developed and consistently implemented to engage them in meaningful activities was discussed with Staff 1 (ED), Staff 2 (Health Services Director/LPN), Staff 3 (RN), and Staff 27 (RCC) on 03/06/24. The staff acknowledged the findings.

HSD/Designee will update care plans and evaluations for Residents (3,4,5,6) for to include more individualized information about preferences, abilities and include a more specific activity plan which details what, when,how and how often staff should offer and assist the residents with more individualized activities, by 4/15/24. ED/HSD/Designee will complete Person Centered Care plans for Dementia and Care Planning in Assisted Living in Relias by 4/15/24. HSD/Designee will review resident evaluations/CP reports weekly to ensure care plans are completed & accurate x4 weeks then quarterly ongoing. Audit results will be reported to QAPI Director and committee at next scheduled meeting.

Based on observation, interview and record review, it was determined the facility failed to ensure their change of ownership survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 282 and C 510.

Refer to C282 and C510

The findings of the change of ownership survey, conducted 03/04/24 through 03/07/24, 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. Tag numbers beginning with the letter H refer to the Home & Community-Based Services 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 first revisit to the change of ownership survey of 03/07/24, conducted 07/15/24 through 07/17/24, are documented in this report. The survey was conducted to determine compliance with 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 the letter C refer to the Residential Care and Assisted Living 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 second revisit to the change of ownership survey of 03/07/24, conducted 09/05/24, are documented in this report. It was determined the facility was in compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation and interview, conducted during a site visit on 12/13/23, it was confirmed the facility failed to have the current staffing plan posted. Findings include, but are not limited to: On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. CS observed in building 950 there was an old staffing plan posted which did not reflect the facility's ABST generated staffing plan. During an interview on 12/13/23, Staff 1 (ED) stated, "I removed the posted staffing plans back in August and did not replace them." It was confirmed the facility failed to have a current staffing plan posted. On 12/13/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: Staff 1 will create and post the required posted staffing plan by the end of the day on 12/13/2023.

Based on observation, interview, and record review, during a site visit conducted on 12/13/23, it was confirmed the facility failed to have service plans readily available to staff. Findings include, but are not limited to: During an interview on 12/13/23, Staff 1 (ED) acknowledged that not all residents current service plans had been added into the service plan binders and had not been readily available to all staff. A review of the service plan binders matched with the resident roster indicated the service plan binder contained a service plan for all residents, but for ten of those residents, the most recent service plan was not available to staff. On 12/13/23, CS observed on Staff 1's computer, all residents to have current quarterly service plans. It was confirmed the facility failed to have a residents most recent service plans readily available to staff. On 12/13/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The RCC will update the service plan binders to reflect all residents current service plans.

Based on interview and record review, conducted during a site visit on 12/13/23, 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 12/13/23, staff members stated the following: "The call light system was down for about a week resulting in call lights not having been answered."   "Call lights not being answered timely has been an ongoing issue at the facility." "Multiple staff call out to their shifts and their shifts are not covered."   "Staff have to work through their lunches due to not having enough staff on the floor."   "Staff are often asked to float from one building to another."    "Resident needs have been missed, such as showers and timely toileting needs."   " There are no staffing plans posted in any building at the moment. " During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following: Buildings 910 and 920 are each staffed with one CG and one MT on day, swing, and night shifts, and the night shift MT oversees all four buildings. Buildings 940 and 950 are each staffed with two CGs and one MT on day and swing shift; and one CG and one MT who oversees all four buildings at once on night shift. A review of the call light log, dated 09/12/23, indicated 26 call light response times that had exceeded 20 minutes. 14 of those response times had exceeded 60 minutes. A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open uncovered shifts. A review of timecards, dated 08/14/23 and 09/12/23, indicated the facility was short staffed for swing and night shift. 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 12/13/23, the findings were reviewed with and acknowledged by Staff 1. Verbal plan of correction: The facility has been hiring 3-6 people per month and will continue to hire. The facility had issues with their call light system that has been resolved.

Based on observation, interview, and record review, conducted during a site visit on 12/13/23, 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: On 12/13/23, CS observed no posted staffing plan in buildings 910, 920, and 940. In building 950 posted was an old staffing plan which did not reflect the facility's ABST generated staffing plan. During an interview on 12/13/23, Staff 1 (ED) stated the facility currently staffed with the following: Buildings 910 and 920 are each staffed with one CG and one MT on day, swing, and night shifts, and the night shift MT oversees all four buildings. Buildings 940 and 950 are each staffed with two CGs and one MT on day and swing shift; and one CG and one MT who oversees all four buildings at once on night shift. During separate interviews, Staff 2 (CG) and Staff 5 (MT) stated the facility had been short staffed, often pulling staff from one building to another. Staff 2 stated, "There are many open shifts on the schedule that do not get filled. When staff are scheduled, there are frequent call outs." A review of the CG and MT schedules, dated 08/01/23 through 10/31/23, indicated several open shifts for every or every other day. The facility was not consistently staffing to the staffing hours generated in the ABST. The facility's ABST indicated the following staffing levels are required to meet the scheduled needs of residents: ·Building 910 and 920 (assisted living): oDay: 2 care staff in each building. oSwing 2 care staff in each building. oNight: 1 care staff in each building. ·Building 940 (memory care): oDay: 3 care staff. oSwing 2 care staff. oNight: 1 care staff. ·Building 950 (memory care): oDay: 2 care staff. oSwing 1 care staff. oNight: 1 care staff. It was confirmed the facility failed to adopt an acuity-based staffing tool (ABST) to determine appropriate staffing levels for the facility. On 12/13/23, the findings were reviewed with and acknowledged by Staff 1.

The findings of the on-site investigation, conducted 12/13/2023, 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. 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

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 six house kitchens on 5/9/23 at 10:25 am through 2:00 pm revealed the following: 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: * Window seals; * Kitchen drains; * Ceiling, fire sprinklers and vents; * Interior and exterior of microwaves; * Stove/grill/oven knobs, doors, interior, exterior; * Hood above grill/stove with large accumulation of dirt/grease debris on removable vent covers; * Large can openers and housings; * Light fixtures and areas of ceiling; * Reach in refrigerators and freezer handles, exteriors and interiors in all kitchen areas; * Floors in all kitchen areas; * Ice machine with mold like substance in interior as well as mineral build up; * Thresholds and corners with build up of dirt/debris; * Wood door ways; * Plastic shelving in dry storage area; * Cambro food carts; and * Walls with spatter/drips/dust. b. The following areas were found in need of repair: * Dishwasher hood vent rusted and with dust buildup; * Multiple light fixtures broken/cracked; * Laminate flooring with cracks/tears, chips in multiple areas/buildings; * Window screens with holes; * Gaps in windows near air conditioning units allowing dust/dirt/debris/pests to enter kitchen areas; * Some windows with build up of black mold like substance; * Microwave in kitchen with rust/damage making un-cleanable surfaces in interior; * Multiple metal shelves with damage and/or rust; * Wooden shelves with damage/exposed wood and not smooth/cleanable surfaces; * Vents/fire sprinklers in kitchen with dust/dirt build up; * Interior refrigerator shelving with areas of pealing and exposed metal which was covered in a rust type substance; * Gaps in some of the sprinkler mounts; * Cove base loose, warped and pealing off wall in areas; * Multiple pots/pans with darkened carbon and grease debris; and * Accumulation of water under prep areas/sinks with saturated towel on the floor. c. Food items found in refrigerator and freezers that were not covered to prevent potential contamination. Multiple food items found without dates when opened and/or prepared. Multiple potentially hazardous food items past their manufactured listed use by dates. d. Multiple cutting boards found to be heavily scored and/or stained. Food contact surfaces of equipment not covered or protected from contamination when stored. e. Facility was not monitoring dishwasher to ensure effectively sanitizing dishes/utensils. f. Facility not using pasteurized eggs for soft/undercooked egg items. g. Shell eggs stored directly above bags of shredded chesses. Produce items stored on raw bacon case/box. h. Sanitizing rags stored on counter and were visibly soiled. Kitchen staff unaware of proper concentration of sanitization solution and was found prepared at a higher concentration than recommended. i. Kitchen staff with long acrylic nails were not using gloves during meal service. Multiple kitchen staff preparing and service foods without hair/facial hair restrained. Kitchen staff observed to touch ready to eat food items with bare hands. Staff not observed to wash hands between tasks to prevent potential contamination. j. Mop buckets and mop stored next to clean/sanitized dishes. k. Multiple hand washing sinks were without soap and/or paper towels to ensure ability for staff to effectively wash hands upon entry to kitchen areas and when hands were potentially soiled or contaminated.  One kitchen staff was observed to wash hands in the 3 compartment sink instead of dedicated hand washing station sink. l. Meals delivered to resident rooms were not covered to protect from potential contamination during transport. Staff 2 (Dietary Services Director)  and Staff 1 (Executive Director) toured the kitchen areas with the Surveyors on 5/9/23. They acknowledged the above areas needing cleaning/repair and attention.

Community to put in place new cleaning schedules and calendars to ensure proper throurough completion the Food Service Manager will audit all kitchens on a weekly basis and Executive Director with Food Service Manager will inspect together one kitchen for cleanliness and to ensure good repair.   Broken or cracked light fixtures have been ordered and will be replaced no later than 6/15/23. Sherwin Williams Flooring coming to the community to provide needed repairs to laminate flooring. Screen ordered and will be replaced no later than 6/15/23. Two microwaves have been disposed of and new microwaves have been ordered. Wood shelving in 940 and 950 to be removed and replaced with stainless steel wire racks. Review all surfaces with maintenance for cleaning and repair. All refrigerators to be audited on a weekly basis to ensure no hazaradous food, all food covered and dated. All cutting boards were replaced by 5/19/23. In-services to be held on 5/25/23 to cover dishwasher logs, red buckets and sanitizing logs as well as gloves, hairnets and beard nets. Hats ordered for all cooks.

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. This is a repeat citation. Findings include, but are not limited to: Observation of the six house kitchens on 06/29/23 at 9:30 am through 12:00 pm revealed the following: 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: * Windows, window frames, and window seals; * Kitchen drains; * Stove/grill/oven interior and exterior; * Light fixtures and areas of ceiling; * Reach in refrigerators and freezer interiors; * Wood dry storage shelves were observed with an accumulation of ants; * Thresholds and corners with build up of dirt/debris; and * Walls. b. The following areas were found in need of repair: * Flooring with cracks/tears, chips in multiple areas/buildings; * Some windows and window frames with build up of black mold like substance; * Microwave interior with rust/damage making an un-cleanable surface; * Multiple metal preparing tables with damage and/or rust; and * Multiple pots/pans with darkened carbon and grease debris. c. Food items found in freezer were not covered to prevent potential contamination and were found without dates when opened and/or prepared. d. Kitchen staff preparing and serving foods was observed without hair being restrained. e. Hand washing sink was without soap to ensure ability for staff to effectively wash hands. On 06/29/23, Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) toured the kitchen areas and the above areas needing cleaning/repair. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in clean and good repair in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the six house kitchens on 10/02/23 between 9:30 am and 11:00 am showed the following areas were in need of cleaning or repair: * Windows, window frames, and window seals had black accumulation, dirt, debris and dead insects; * Reach in refrigerators and freezer interiors had numerous spills, splatters or debris on doors and shelves. Multiple units had broken or missing pieces from interior shelves or doors; * Wood shelves in the dry storage areas had chips and scrapes with exposed wood; * Black accumulation was noted to baseboard edges and thresholds; * Microwaves in three houses had significant splatters and spills on the interior of the units; * Flooring in multiple areas/houses had cracks, tears, missing pieces or bubbling up at the edges near drains and walls; and * Multiple sheet pans had darkened carbon and grease debris. Staff 2 (Culinary Services Director) toured all areas in need of cleaning or repair with the surveyor, on 10/02/23. The areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 2. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in clean and good repair in accordance with the Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observation of the six house kitchens on 02/27/24 between 11:00 am and 12:45 pm showed the following areas were in need of cleaning or repair: * Windows, window frames, and window sills had black accumulation, dirt, debris and dead insects; * Reach in refrigerators and freezer interiors had numerous spills, splatters or debris on doors and shelves. Multiple units had broken or missing pieces from interior shelves or doors; * Wood shelves in the dry storage areas had chips and scrapes with exposed wood; * Black accumulation was noted to baseboard edges and thresholds; * Microwaves in three houses had significant splatters and spills on the interior of the units; * Flooring in multiple areas/houses had cracks, tears, missing pieces or bubbling up at the edges near drains and walls; * Multiple sheet pans had darkened carbon and grease debris; * Multiple cutting boards with staining and heavily scored; * Outside garbage/refuse area with trash/debris on the ground created an area which could attract rodents/pests; * Multiple items found in reach-in refrigerators without open dates/prepared dates/use by dates as required; * Floors in multiple kitchen areas found with dirt debris/food debris/splatters/spills; * Large blanket towels were found under sink in building 910 saturated with water and a slow draining sink; * Hood vents in building 940 and 950 with large accumulation of dirt/dust/grease debris; * Ceiling vents with noted dust/dirt/debris; * Microwave in building 910 was damaged with non smooth/cleanable surface; * Building 950 had large hole in the ceiling directly over food prep surfaces/area where items from ceiling could potentially fall into or onto food and equipment; * Multiple food items in dry storage were found open to potential contamination or not securely closed and dated when opened; * Multiple kitchens had sponges for cleaning equipment that had chunks and pieces missing; * Multiple reach-in fridges had staff food or beverages stored with resident food; and * Food service stainless steal cart and hotel pan found stored in garbage/refuse area, staff member then observed taking to a house/building. Unknown amount of time food service equipment stored near garbage/refuse. Staff 2 (Culinary Services Director) toured all areas in need of cleaning or repair with the surveyor, and acknowledged the issues. The areas in need of cleaning and repair were discussed with Staff 1 (ED) and Staff 2. They acknowledged the multiple findings.

Based on interview and record review, it was determined the facility failed to ensure staff member's whose duties included preparing food, had a food handler's certificate for 1 of 6 sampled employees (# 3) whose food handler's card were requested.  Findings include, but are not limited to: There was no documented evidence Staff 3 (Cook) had a food handlers card when the surveyors entered the facility for the annual kitchen survey. Ensuring food handler's card were active for employees whose duties included preparing food was discussed with Staff 2 (Dietary Services Director) on 05/12/23 at 10:00 am.  Staff acknowledged the finding.

All employees now have a current food handler card. The missing employee on the date of inspection's card had expired. All food handler cards have been uploaded to ADP as well as printed and placed on the wall in the Food Service Director Office. Food Service Director has also put expiration dates on the calendar as well as reminders put in her calendar for two weeks prior to expiration.

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.

Community to put in place new cleaning schedules and calendars to ensure proper throurough completion the Food Service Manager will audit all kitchens on a weekly basis and Executive Director with Food Service Manager will inspect together one kitchen for cleanliness and to ensure good repair.   Broken or cracked light fixtures have been ordered and will be replaced no later than 6/15/23. Sherwin Williams Flooring coming to the community to provide needed repairs to laminate flooring. Screen ordered and will be replaced no later than 6/15/23. Two microwaves have been disposed of and new microwaves have been ordered. Wood shelving in 940 and 950 to be removed and replaced with stainless steel wire racks. Review all surfaces with maintenance for cleaning and repair. All refrigerators to be audited on a weekly basis to ensure no hazaradous food, all food covered and dated. All cutting boards were replaced by 5/19/23. In-services to be held on 5/25/23 to cover dishwasher logs, red buckets and sanitizing logs as well as gloves, hairnets and beard nets. Hats ordered for all cooks.

Based on observation, record review 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 240.

Based on observation, record review 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 240.

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 C240.

Based on interview, observation and review of documentation, 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 C 240.

Based on interview, observation, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C 240.

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to C240.

The findings of the kitchen inspection, conducted 5/9/23, 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 revisit for the kitchen inspection on 05/09/23, conducted 06/29/23, 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 second revisit to the kitchen inspection of 06/29/23, conducted 10/02/23, 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 third revisit to the kitchen inspection of 05/09/23, conducted 02/27/24, 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 fourth revisit to annual kitchen inspection of 05/09/23, conducted 07/15/24 through 07/17/24, 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 record review and interview, it was confirmed that the facility failed to ensure that the service plans are getting updated quarterly. Findings include: A review of Resident #1-3 (R1-3) service plan showed that the facility did not update quarterly. The service plans are dated 08/31/2022, 07/27/2022, and 07/17/2022. On 04/19/2023, these findings were reviewed and acknowledged by S1.

Based on interview and record review 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: During separate interviews 04/19/2023, Staff #1-2 (S1-2) stated that their current staffing levels for each building are 1 Med Tech (MT) and 1 Caregivers (CG) every shift for building 910 and 920. For buildings 940 and 950, 1 MT and 2 CG for day and swing shift and 1 MT and 1 CG for NOC shift. A record review of the posted staffing plan, Resident #1-3 (R1-3) service plans dated 08/31/2022, 07/27/2022, and 07/17/2022, progress notes from 03/29/2023 - 04/17/2023, the breakdown of their care on the facility's ABST, and the ABST for the whole facility. R1-3 service plans had not been updated quarterly. The ABST revealed the facility is not staffing to the levels required per the facilities tool. On 04/19/2023, these findings were reviewed and acknowledged by S1.

Based on interview and record review it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool (ABST). Findings include: During separate interviews on 04/19/2023, Staff #1-2 (S1-2) stated that their current staffing levels for each building are 1 Med Tech (MT) and 1 Caregivers (CG) every shift for building 910 and 920. For buildings 940 and 950, 1 MT and 2 CG for day and swing shift and 1 MT and 1 CG for NOC shift. S2 stated that the facility has been attempting to hire another CG for building 950. A record review of the posted staffing plan, Resident #1-3 (R1-3) service plans dated 08/31/2022, 07/27/2022, and 07/17/2022, progress notes from 03/29/2023 - 04/17/2023, and the breakdown of their care on the facility's ABST. R1-3 service plans had not been updated quarterly. The exported data in the ABST showed 49 of the 54 residents entered in the tool to not have been evaluated quarterly with last updated on 12/12/2022. On 04/19/2023, these findings were reviewed and acknowledged by S1.

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 04/19/2023.  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 and interview, it was determined the facility failed to ensure the kitchen was clean and following appropriate storage methods in accordance with the Food Sanitation Rules OAR  333-150-0000. Finding include, but are not limited to: On 11/15/22 at 9:50 am, the facility kitchens in House 910, 920, 940, 950 and 960 were observed to need cleaning in the following areas: * Floors in 910, 920 and 940 had debris, food, black matter and stains; * Vents above stoves in 940 and 950 had dust/grease build-up; * Stoves had grease build-up in 940 and 950; and * The refrigerator in 940 had drips and splatters on the outside of the doors. Garbage cans were uncovered when not in use in 920, 940 and 960. Refrigerators in 910, 920 and 940 did not have thermometers. Fresh shell eggs were stored on the top shelf of refrigerator in 920. Scoops were stored in food containers in 940 and 950 (brown sugar, powdered sugar and oatmeal). The above areas were shared with Staff 1 (Dining Services Director) on 11/15/22. The findings were acknowledged.

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 240.

The findings of the kitchen inspection, conducted 11/15/22, 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 Services Food Sanitation Rules OARs 333-150-0000.