Brookdale Bend

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 ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: On 02/09/26, between 10:15 am and 1:15 pm, the facility kitchen was observed to need cleaning and repair in the following areas: Areas in need of cleaning and/or repair: * Fridge gasket in Claire kitchenette - loose, detached, preventing seal/door closure; * Cutting boards - heavily scored, stained, non-cleanable; * Floor under the two sinks - missing and/or loose tiles, exposed concrete, porous, non-cleanable surfaces; and * Dish machine - wash temperature below minimum required during survey, and for two consecutive days prior to survey, and staff continued to use the machine. During an observation on 02/09/26 at approximately 11:30am, Staff 1 (PIC/Dining Services Manager) demonstrated the dish machine did not meet minimum temperature requirements. Staff 1 verified that the machine had not met temperature requirements for two consecutive days prior to survey and staff had continued to use the machine. Staff planned to use the three-compartment sink for ware washing until the repair was made. During an observation on 02/09/26 at approximately 12:15 pm, surveyor observed refrigerator temperatures in the Claire kitchenette to be above the maximum required temperature and noticed the gasket was detached, keeping the door ajar. Staff 1 and Staff 3 (Maintenance Director) reported that they were unaware of the detached gasket. The surveyor observed documentation of temperatures above maximum temperature for approximately five days. Staff planned to adjust the temperature of the refrigerator, discard any potentially hazardous food, monitor temperatures, and make repairs. During record review of the temperatures of the refrigerator in the Bridge kitchenette, the surveyor noticed several temperatures above the maximum required temperatures. Staff 1, Staff 2 (Executive Director), and Staff 3 reported that they were unaware of the refrigerator being above the required temperature. Staff planned to adjust and monitor the refrigerator temperatures. The areas of concern were observed and/or discussed with Staff 1 (PIC/Dining Services Manager), Staff 2 (Executive Director), and Staff 3 (Maintenance Director). Staff acknowledged the findings at approximately 1:15 pm on 02/09/26.

Facility will ensure adherance to kitchen practices and protocols in accordance with the Food Sanitation Rules OAR 333-150-000 by doing the following: - Replacing both kitchenette fridge seals and evaporator fans and cleaning the consendor motors. Motors will be cleaned every six months, and fridge gaskets will be checked every two months by Maintenance Supervisor and replaced as needed. - Purchasing new cutting boards, which will be replaced at least annually unless sooner is indicated by visible wear and tear. - Exposed concrete underneath the two-sink from a prior drain pipe repair will be replaced with a new drain. Vendor has been contacted and project is anticipated to be completed by end of March 2026. - Dishwashing machine thermostat was adjusted by EcoLab to meet temperature sanitation requirements. To prevent this violation from occurring again, staff will check the thermometer prior to each wash cycle to ensure wash temperature is at least 150 degrees and rinse temperature is at least 180 degrees. If temperature falls outside of these ranges, staff will utilize the three-sink method. - Monitoring kitchenette refrigerators by using remote app with temperature sensors, as well as ensuring refrigerators in kitchenettes are locked after each meal. Executive Director, Dining Services Coordinator and Maintenance Supervisor will be responsible to see that corrections are completed and monitored.

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 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 C240.

See C240.

OAR 411-057-0140(2) Administration Compliance (2) The licensee of a memory care community must comply with both the licensing rules for the facility and Chapter 411, Division 57.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

?Based on observation, interview, and record review, it was determined the facility failed to ensure a safe medication system and failed to ensure adequate professional oversight for residents. The number of discrepancies and the severity of concerns placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to: During the re-licensure survey, conducted 11/03/25 through 11/06/25, the facility failed to ensure a safe medication system, and administrative oversight was found to be ineffective based on discrepancies and the level of severity in the following area: C 302: Systems: Tracking Controlled Substances. On 11/05/25 at 4:20 pm, the survey team informed Staff 1 (ED), Staff 2 (Health and Wellness Director, RN), and Staff 22 (District Director of Operations) that the failure to have a safe medication administration, as indicated by the extensive number of discrepancies with the narcotic tracking log and the MAR, created the potential of harm and constituted a situation that required an immediate plan of correction. The facility presented a plan of correction on 11/05/25 at 5:46 pm. The immediate risk was addressed; however, the facility will need to evaluate the overall system failures associated with the licensing violation. Failure to ensure a safe medication system and to ensure adequate professional oversight based on deficiencies related to medication administration was discussed with Staff 1, Staff 2, and Staff 22 on 11/05/25. The staff acknowledged the findings. Refer to C302.

OAR 411-054-0055 (1)(a) Systems: Medications and Treatments (1) MEDICATION AND TREATMENT ADMINISTRATION SYSTEMS. The facility must have safe medication and treatment administration systems in place that are approved by a pharmacist consultant, registered nurse, or physician.(a) The administrator is responsible for ensuring adequate professional oversight of the medication and treatment administration system.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

Based on observation, interview, and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 4 of 4 sampled residents (#s 1, 2, 4, and 7) whose MARs and Controlled Substance Disposition logs were reviewed. Resident 1, 2, 4, and 7’s narcotic pain medication was not tracked effectively to ensure the medication was administered as ordered. The lack of accurate documentation of narcotic medication administrations put Residents 1 and 2 at increased risk for unaddressed pain. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 01/2025 with diagnoses including dementia. Resident 2 clinical records noted the resident sustained a fall with a hip fracture on 09/13/25, with surgical repair. The resident's 08/10/25 through 11/03/25 progress notes, 09/19/25 signed physician orders, and the 10/01/25 through 11/03/25 MAR/TAR were reviewed. The resident had an order for hydrocodone-acetaminophen 5-325mg, take one tablet every six hours PRN for pain. The resident's Controlled Substance Disposition logs and MARS dated 10/01/25 through 11/03/25, and observation of the medication cards on 11/05/25, showed the following: The following 50 doses were reflected on the disposition log, but were not signed as administered on the MAR. * On 10/02/25 doses noted at 5:30 am, 3:18 pm, and 9:18 pm; * On 10/03/25 doses noted at 4:27 am and 10:30 am; * On 10/04/25 a dose noted at 5:37 am; * On 10/06/25 a dose noted at 5:00 am; * On 10/07/25 a dose noted at 5:18 am; * On 10/08/25 doses noted at 5:37 am, 11:00 am, 4:14 pm, and 8:08 pm; * On 10/09/25 doses noted at 5:00 am and 10:18 am; * On 10/10/25 doses noted at 5:04 am, 10:16 am, 3:00 pm, and 10:14 pm; * On 10/11/25 a dose noted at 5:00 am; * On 10/12/25 doses noted at 5:18 am and 11:37 am; * On 10/13/25 doses noted at 5:35 am, 10:45 am, and 3:01 pm; * On 10/14/25 doses noted at 3:01 pm and 10:00 pm; * On 10/15/25 doses noted at 11:00 am and 8:00 pm; * On 10/16/25 doses noted at 5:37 am, 10:18 am, 2:48 pm, and 8:00 pm; * On 10/17/25 a dose noted at 5:00 am; * On 10/18/25 a dose noted at 6:00 am; * On 10/19/25 doses noted at 4:04 am and 10:46 am; * On 10/20/25 a dose noted at 5:00 am; * On 10/23/25 doses noted at 6:00 am and 2:59 pm; * On 10/24/25 doses at 5:56 am and 3:45 pm; * On 10/25/25 doses noted at 4:58 am and 11:59 am; * On 10/26/25 doses noted at 5:00 am, 11:00 am, and a dose with an illegible time; * On 10/27/25 a dose noted at 5:00 am; *On 10/29/25 a dose noted at 5:36 with no am or pm noted; * On 11/02/25 a dose noted at 5:45 am; and * On 11/03/25 a dose noted at 4:48 am. Two doses administered were recorded on the MAR but not on the Controlled Substance Disposition log: * On 10/21/25 a dose noted at 5:01 am; and * On 10/25/25 a dose noted at 6:33 pm. In an interview on 11/04/25, Staff 15 (MT) indicated the resident had one active card that was in use. The resident would not typically initiate a request for medication but could respond to simple questions about his/her pain. The resident would sometimes deny the need for any medication even when s/he seemed to be in pain. The disposition log and the pill card both reflected a count of 17 pills remaining. Staff 15 further indicated they watched for signs and symptoms of pain, as well as any verbal indicators from the resident, and would offer the resident his/her PRN pain medication. In interview attempts between 11/03/25 and 11/05/25, it was difficult to obtain information from Resident 2. The resident could answer simple questions but veered off topic during parts of the conversation. The resident indicated s/he had pain on 11/03/25, and no additional statements of pain were offered by the resident during interview attempts. The resident did not indicate any additional concerns or needs at the time of the conversations. In an interview on 11/05/25, Staff 2 (Health and Wellness Director/RN) indicated she was aware of an issue with another resident and medication administrations not saving in the computer. She was not aware of any issues with Resident 2 and had no additional information on why 50 narcotics were signed out on the disposition log, but not reflected as administered on the MAR. The need to ensure narcotic disposition logs, MARs, and medication cards accurately reflected medication administered was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/RN), and Staff 22 (District Director of Operations) on 11/05/25. The staff acknowledged the findings. 2. Resident 1 was admitted to the facility in 09/2025 with diagnoses including dementia. The resident had chronic pain with ongoing issues with his/her knees. The resident's 09/01/25 through 11/03/25 progress notes, 10/24/25 signed physician orders, and the 10/01/25 through 11/03/25 MAR/TAR were reviewed. The resident had orders for tramadol 50 mg, take one tablet every six hours PRN for knee pain; oxycodone 5 mg, take one tablet every two hours PRN for severe pain or shortness of breath; and lorazepam 0.5 mg, take one tablet every 12 hours PRN for anxiety or mild agitation. The tramadol was discontinued on 10/27/25. The resident's Controlled Substance Disposition logs and MARS dated 10/01/25 through 11/03/25, and observation of the medication cards on 11/05/25, showed the following: The following doses were reflected on the disposition log, but were not signed as administered on the MAR. Tramadol: * On 10/21/25 a dose noted at 9:00 am; and * On 10/28/25 a dose noted at 9:25 am. Lorazepam: * On 10/29/25 a dose noted at 10:00 am; * On 10/03/25 a dose noted at 6:00 pm; * On 10/04/25 a dose noted at 6:30 pm was on the disposition log but the MAR showed dose at 9:30 pm; * On 10/06/25 a dose noted at 4:00 pm showed two tablets were signed out on the disposition log instead of one tablet and nothing was recorded on the MAR; and * On 10/07/25 a dose noted at 5:45 pm showed two tablets were signed out on the disposition log instead of one tablet and the MAR did not reflect two tablets and showed the administration time as 4:45 pm. Oxycodone: * On 10/25/25 a dose noted at 1:43 pm; * On 10/26/25 doses noted at 5:00 am and 11:00 am; * On 10/27/25 a dose noted at 4:55 no indication of am or pm and a dose at 6:50 pm; * On 10/28/25 doses noted at 4:18 pm and 8:01 pm; * On 10/29/25 doses noted at 4:00 am, 5:18 am, and 8:14 pm; * On 10/30/25 doses noted at 6:00 am, a dose with unclear administration time, and a dose at 8:01 pm; * On 10/31/25 doses noted at 5:01 am, 10:30 am, and 9:00 pm; * On 11/01/25 doses noted at 3:50 am, 6:00 am, and 3:06 pm; and * On 11/02/25 doses noted at 5:16 am and 11:00 am. The following Oxycodone administrations were recorded on the MAR but not on the disposition log: * On 10/29/25 a dose noted at 10:00 am. An Oxycodone dose on 10/29/25 at 10:00 am was crossed out, with no other notation for an error, and the medication count decreased by one from 15 to 14 pills. There was no documentation that any medications were destroyed. In an interview on 11/04/25, Staff 15 (MT) indicated the resident had multiple active cards between the PRN Oxycodone and the scheduled Oxycodone. Staff 15 indicated that sometimes the scheduled medication was pulled from the PRN card, and the PRN medication was pulled from the scheduled, but not often. The counts for the resident’s active and full cards matched the counts reflected on the disposition logs. The tramadol no longer had a card as the medication was previously discontinued and removed. Staff 15 stated the resident had pain most of the time to his/her back and/or knees, the resident could express pain verbally, and staff watched for nonverbal signs. The resident would not initiate a request for medication, and it was sometimes difficult to administer medications to him/her. In interview attempts between 11/03/25 and 11/05/25, Resident 1 was not able to offer much information regarding his/her care. The resident answered yes to questions of pain when asked. The resident could sometimes answer basic questions if s/he wanted to engage. The resident had a lot of anxiety, distress, and behaviors, including yelling out, crying, grabbing at staff, and attempting to stand. The resident’s anxiety and distress increased whenever staff left him/her alone for any length of time while the resident was awake. In an interview on 11/05/25, Staff 2 (Health and Wellness Director/RN) indicated she was aware of an issue with another resident and medication administrations not saving in the computer. She was not aware of any issues with Resident 2 and had no additional information on why numerous narcotics were not reflected as administered on the MAR. The need to ensure narcotic disposition logs, MARs, and medication cards accurately reflected medication administered was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director/RN), and Staff 22 (District Director of Operations) on 11/05/25. The staff acknowledged the findings. 3. Resident 4 was admitted to the facility in 09/2025 with diagnoses including dementia without behavioral disturbance. Resident 4 had a physician order for oxycodone 5 mg, give one tablet by mouth every two hours as needed for severe pain or dyspnea. Resident 4's 10/01/25 through 11/03/25 MARs and Controlled Substance Disposition Logs were reviewed, and the following was identified: Between 10/01/25 and 10/10/25, there were six occasions staff documented on the MAR the PRN oxycodone was administered; however, there was no drug disposition log available for those six administrations. The dates for those administrations were as follows: * 10/06/25 – three times; * 10/07/25 – one time; * 10/08/25 – one time; and * 10/10/25 – one time. Discrepancies between the drug disposition log and the MAR were reviewed with Staff 1 (ED) and Staff 3 (ED, Brookdale Redmond) on 11/06/25 at 1:25 pm. Staff 3 stated the drug disposition log page with the above administration dates could not be located. The need to ensure the facility had a system for accurately tracking controlled substances administered by the facility was discussed with Staff 1 on 11/06/25 at 1:25 pm. She acknowledged the findings. Resident 7 moved into the facility in 06/2024 with diagnoses including dementia. Staff reported during the acuity interview on 11/03/25 that the resident experienced significant hip pain and underwent hip replacement surgery on 10/15/25. The resident had a signed physician order for hydrocodone-acetaminophen 10-325 mg, one tablet to be administered every six hours, up to three times daily, for hip pain as needed. Review of the resident's 10/02/25 through 11/03/25 MARs and Controlled Substance Disposition logs revealed the following: a. On the following dates, 20 doses of PRN hydrocodone were documented in the Controlled Substance Disposition log as having been removed for administration, but were not documented as administered on the MAR: * 10/02/25 at 5:00 am and 8:00 pm; * 10/03/25 at 5:18 am and 8:00 pm; * 10/04/25 at 5:00 am; * 10/07/25 at 5:00 am; * 10/08/25 at 10:00 pm; * 10/09/25 at 2:00 pm and 10:01 pm; * 10/10/25 at 5:04 am, 10:37 am, and 7:00 pm; * 10/11/25 at 6:09 pm; * 10/13/25 at 5:00 am; * 10/14/25 at 10:12 pm; * 10/19/25 at 10:00 pm; * 10/20/25 at 8:18 pm; * 10/31/25 at 1:26 am; * 11/01/25 at 8:00 am; and * 11/01/25 at 6:00 pm. b. On 11/03/25 at 10:56 pm, PRN hydrocodone was documented as administered on the MAR but was not documented in the Controlled Substance Disposition log. While reviewing the above findings on 11/06/25 at 2:00 pm, Staff 1 (Executive Director) and Staff 2 (Health and Wellness Director/RN) acknowledged that they were not previously aware of the inconsistencies in tracking PRN hydrocodone for Resident 7 and had no additional information to provide. The need to ensure the facility had a system for tracking controlled substances was reviewed with Staff 1, Staff 2, Staff 3 (ED, Brookdale Redmond), and Staff 4 (District Director of Clinical Services) on 11/06/25 at 2:00 pm. They acknowledged the findings.

OAR 411-054-0055 (1)(e) Systems: Tracking Control Substances (e) The facility must have a system approved by a pharmacist consultant or registered nurse for tracking controlled substances and for disposal of all unused, outdated or discontinued medications administered by the facility.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

?Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C300 and C302.

OAR 411-057-0160(2b) Compliance with Rules Health Care (b) Health care services provided in accordance with the licensing rules of the facility.

Based on observation, interview, and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchenettes, food storage areas, food preparation, and food service on 02/22/24 noted a buildup of splatters, spills, drips, and debris on:   - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of the walk-in refrigerators and reach in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans. * Multiple packed food items were not dated when opened. * Raw eggs were stored over vegetables. * Scoops and spoons were left in bulk bins of foods. * Significantly dented canned food item noted in the dry storage. * There was not a small diameter probe thermometer to measure thin foods. * There was no evidence of monitoring the sanitizing solution to ensure it was at the correct ratio. * There was no evidence of monitoring temperatures of refrigerators, cooked foods, or the ware washer. * High temperature ware washer was not reaching the required water temperature. Staff 1 (Executive Director) and Staff 2 (Dietary Services Director) agreed to sanitize dishes in the triple pot sink until the issue was resolved. * Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food. Staff 1 (Executive Director), Staff 2, and the surveyor toured the kitchens on 02/22/24. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintaned in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the facility main kitchen, kitchnettes, food storage areas, food preparation, and food service on 2/22/24 noted a buildup of splatters, spills, drips and debris on: - Exteriors and interiors of reach-in refrigerators and freezers on each unit; - Exterior of cupboards and walls in unit refrigerator areas; - Floor of walk-in refrigerators and reach-in freezer in the main kitchen; - Can opener casing; and - Lids and sides of garbage cans POC: ED added kitchenette cleaning to NOC shift assignment and reviewed standards/expectations for cleaning the kitchenettes. Care staff to clean nightly and Dining Services Coordinator to check weekly to ensure it is being cleaned thoroughly. Can opener casing, walk-in refrigerator and reach-in freezer cleaned immediately and added to weekly/monthly cleaning list for Dining Services Team to ensure they are on regular cleaning schedule. - Multiple packed food items were not dated when opened. POC: DSC reviewed this with cooks, disposed of undated items and ED reviewed with care staff during February all staff meeting. This will be part of daily end of shift check to ensure all items are dated and prevent reoccurrence. - Raw eggs were stored over vegetables. POC: Eggs were immediately moved to the bottom shelf. DSC reviewed this with cooks. To prevent reoccurrence, DSC/cook to check walk-in daily for temperatures, dates, and product placement (e.g. eggs on bottom shelf) at the end of each shift. - Scoops and spoons were left in bulk bins of foods. POC: Scoops and spoons removed from bulk bins. This was reviewed during February's all staff meeting with care staff, but signs have also been placed on bins reminding all staff not to store scoops/spoons in bulk bins and this will be part of the end of shift checklist for Dining Services. - Significantly dented canned food item noted in the dry storage. POC: Item moved to a separate storage location immediately to be returned to vendor. During each shipment, DSC and cooks to check for significantly dented items and to notate immediately that item is to be returned to prevent staff from accidentally using item before being returned. - There was not a small diameter probe thermometer to measure thin foods. POC: DSC located small diameter probe thermometer to use for measuring thin foods. Dining Services Team aware and will utilize moving forward. - There was no evidence of monitoring temperatures of refrigerators, cooked foods or the ware washer. POC: Temperature logs were replaced immediately. To prevent reoccurrence, Dining Services Team to take food, refrigerator and freezer temps and log them for each meal. ED to check for compliance weekly. - High temperature ware washer was not reaching the required water temperature. POC: EcoLab was contacted immediately to service machine and Dining Services Team sanitized dishes in the triple pot sink until the issue was resolved. To prevent reoccurrence, Dining Services Team to check temperature daily to ensure temps are falling within the requirements. - Caregiving staff, who provided incontinent care to residents, were not using aprons while serving food. POC: Aprons purchased and in-service held on 2/29/24 to communicate this requirement for all care staff who are serving food after providing incontinent care to residents. Management team rotating days on the floor during mealtimes to ensure compliance.

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

Refer to C 240

The findings of the kitchen inspection, conducted 02/22/24, 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 revisit to the kitchen inspection of 02/22/24, conducted 05/08/24, 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 and OARs 411 Division 57 for Memory Care Communities.

Based on interview and record review, conducted during a site visit on 02/01/24, it was confirmed the facility failed to carry out medication and treatment orders as prescribed for 12 of 12 sampled residents (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12). Findings include, but are not limited to: A review of Residents 1, through 12's, Medication Administration Record (MAR), Progress notes, dated 11/03/23 through 11/12/23, and in house investigation dated 11/10/23 through 11/13/23 that was reported to APS (Adult Protective Services) confirmed the following medications were not administered. 1) Resident 1 had a physician order for Levothyroxine 0500, to administer one time daily at 5 am. Missing doses were 11/05/23, 11/07/23, 11/08/23, and 11/09/23. 2) Resident 2 had a physician order for Levothyroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 3) Resident 3 had a physician order for Levohtyroxine 0500 to administer one time daily at 5am. Missing doses were 11/04/23, 11/07/23, 11/08/23, 11/09/23, 11/10/23, and 11/11/23. 4) Resident 4 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23, and 11/12/23. 5) Resident 5 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 6) Resident 6 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 7) Resident 7 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23, 11/11/23, and 11/12/23. 8) Resident 8 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/07/23, 11/08/23, and 11/09/23. 9) Resident 9 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 10) Resident 10 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/03/23, 11/07/23, 11/08/23, and 11/09/23. 11) Resident 11 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/08/23, 11/09/23, and 11/10/23. 12) Resident 12 had a physician order for Levothroxine 0500 to administer one time daily at 5am. Missing doses were 11/09/23, 11/10/23, 11/11/23 and 11/12/23. In an interview on 02/01/24 at 10:25 am, Staff 1 (ED) and Staff 2 (Health and Wellness director) confirmed they were aware of the incident, and had reported the incident to APS as required, and the employee involved had been counseled extensively and completed multiple Relias courses on medication errors. Staff 2 stated that physicians and families were notified of the medication errors, and that residents affected were monitored and there was no negative outcome to the residents. The above information was shared with Staff 1 on 02/01/24. S/he acknowledged the findings. It was confirmed the facility failed to carry out medication and treatment orders as prescribed. Verbal Plan of Correction: ED states that they will continue to report all medication errors to the State right away. ED states that they have provided training to all staff and went over medication errors and are reporting to MT, Administration and RN immediately. ED & RN are performing daily clinicals.

The findings of the on-site investigation, conducted 04/09/24 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 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 interview and record review, conducted during a site visit on 09/27/23, it was confirmed the facility failed to fully implement an Acuity-Based Staffing Tool for 3 of 3 sampled residents (#s 1, 2, and 3). Findings include, but are not limited to: During an interview on 09/27/23, Staff 2 (Administrator) stated the facility is currently working with the district team to ensure that all 22 Activities of Daily Living (ADLs) are listed, for each resident in the tool. On 10/02/23, a record review of the facility's ABST report, dated 10/02/23, showed only 17 ADLs were listed for each resident. The occupancy listed on the tool was 49 and the census on 10/02/23 was 49. The findings of the investigation were reviewed with and acknowledged by Staff 2 on 09/27/23. It was determined the facility failed to fully implement an Acuity-Based Staffing Tool. Verbal Plan of Correction: The district team is working to include all 22 ADLs in the tool. Projected date of compliance unknown.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and food was prepared in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: Observations of the kitchen and meal preparations on 06/06/22 and 06/07/22 showed the following: * Multiple walls and shelves throughout the kitchen and dishware areas had dried spills, splatters and food debris; * Baseboards and floors throughout the kitchen and dishware areas had food debris and black grime build-up; * Shelves and floors in the walk-in freezer and reach-in refrigerators had dried spills and food debris; * One of the garbage cans in the kitchen, used for food disposal, did not have a lid or cover; * There were multiple dented cans of pears and chicken dumplings in the dry storage; * The range hood vent and grates above the stove had an accumulation of grease and thick layer of dust; * The floor drains had food particles and a build-up of sludge and green matter; * The wall above the steam table had some build-up of dust particles; * Kitchen staff were observed resting the probe thermometer on the bottom of food pans in the steam table when obtaining food temperatures and did not sanitize the probe between foods while temperatures were obtained; and * Kitchen staff were observed using the same gloved hands between touching clean and dirty surfaces without changing gloves. The need to ensure the kitchen was kept clean and proper sanitization and food handling techniques were used was discussed with Staff 1 (ED) and Staff 6 (Dietary Manager) on 06/07/22. They acknowledged the findings.

1. Dented cans were removed. Hood and vents were professionally cleaned. Kitchen was cleaned. Kitchen staff were educated on proper temping techniques and sanitation with temping and food handling. Community replaced garbage can with one that has a lid. 2.  The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been educated on checking for dented cans and sending them back to the supplier. 3.  The Dietary Manager and/or a designee will verify that cleaning schedule is being implemented and completed daily, weekly, and monthly. 4. The Dietary Manager and Executive Director are responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the facilities kitchen, food storage areas, food preparation and food service on 10/10/22 revealed: * Splatters, spills, drips and debris noted on: - Surfaces and underneath storage shelves, and cabinets throughout the kitchen; - Storage shelves throughout the kitchen; - Cookware stored on open shelving; - Drains throughout the kitchen; - Interiors of reach in freezers; - Flooring of the walk in refrigerator; - Walls throughout the kitchen; - The dishwashing area walls, floors, and equipment; - Both sides and the interior of the range, grill, and oven; - Behind and underneath appliances; - The surface and underneath the tray line steam table; and - Food delivery carts. * Unlabeled and undated food items were noted in the refrigerators; and * Raw eggs were stored above ready to eat foods. The areas in need of cleaning and the food storage concerns were reviewed with Staff 1 (ED) and Staff 6(Dietary Manager). They acknowledged the findings.

1. Dented can was removed. Kitchen was scrubbed and cleaned prior to survey exit. Kitchen staff were educated on cleaning schedule. All items were fixed; labeled and dated and stored properly. 2.  The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been instructed to place any dented cans in a separate area to notify supplier when putting order away. 3.  The Executive Director or designee will conduct walk throughs of kitchen a minimum of three times a week for 60 days. Executive director or designee will review cleaning schedule three times a week with walk through. 4. The Dietary Manager and Executive Director are responsible for this plan of correction.

Based on observation and interview it was determined the facility failed to ensure the kitchen was clean and maintained 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 facilities kitchen on 12/21/22 revealed food splatters, spills, drips, and debris on the following areas: - Underneath storage shelves, and cabinets throughout the kitchen; - Interiors of drawers; - Bakery racks; - Cookware stored on open shelving and in bakery racks; - Drains throughout the kitchen; - Interiors of reach in freezers; - The dishwashing area walls, shelving, and equipment; - Top and sides of the ice machine; and - Garbage cans. The areas in need of cleaning were reviewed with Staff 1 (ED) and Staff 26 (Dietary Manager). They acknowledged the findings.

1. Kitchen was scrubbed and cleaned after survey exit. Kitchen staff were educated on cleaning schedule. All items were fixed; new dining manager educated on cleaning expectations. 2.  The Dietary Manager will implement daily, weekly, and monthly cleaning assignments. Kitchen staff have been instructed to sign off daily on cleaning tasks. 3.  The Executive Director or designee will conduct walk throughs of kitchen a minimum of three times a week for 60 days. Executive director or designee will review cleaning schedule three times a week with walk through. 4. The Dietary Manager and Executive Director are responsible for this plan of correction.

2. Resident 2 was admitted to the facility in 01/2021 with diagnoses of dementia. On 06/06/22, there was no service plan available to staff for Resident 2. A copy was printed and provided to the surveyor. The service plan, dated 04/20/22, lacked clear direction for staff for the evacuation needs of Resident 2 in the event of an emergency. The need to ensure service plans were available to staff and provided clear direction was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/06/22 and 06/07/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 04/2022 with diagnoses including dementia. On 06/06/22, there was no current service plan available to staff for Resident 3. A copy of the current service plan was printed and provided to the surveyor. The service plan, dated 05/21/22, lacked clear direction for staff for the evacuation needs of Resident 3 in the event of an emergency. The need to ensure service plans were available to staff and provided clear direction was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/06/22 and 06/07/22. They acknowledged the findings. 4. Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia. Resident 4 was observed in bed at all times and relied on staff for all ADL care. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 06/06/22 thru 06/08/22, revealed Resident 4's service plan was not reflective of the resident's status, did not provide specific directions to staff, and staff did not follow the plan in the following areas: * Activity status; * Ambulation status: use of wheelchair vs. bed bound; * Behaviors status; * Toileting status; * Oral Care status; * Emergency evacuation ability; and * Wandering status. On 06/07/22, the service plan was discussed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction. 5. Resident 5 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff, review of the current service plan and clinical records during the survey, from 06/06/22 thru 06/08/22, revealed Resident 5's service plan did not provide instruction to staff and staff did not follow the service plan as outlined in the following areas: * Activity status; * Hand hygiene prior to breakfast with finger food; * Oral Care status; * Shower instruction: bed bath vs. shower with hospice services; * Fall risk and interventions; and * Emergency evacuation ability. On 06/08/22,  the service plan was discussed with Staff 1 (ED). She acknowledged the service plan did not provide clear direction and staff did not follow morning care as outlined.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were updated after a significant change of condition, were reflective of the care needs and preferences of the resident, provided clear direction regarding the delivery of services, and were readily available to staff for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia. The resident's 05/05/22 service plan and temporary care plans were reviewed. The service plan was not reflective of the resident's current care needs and did not provide clear caregiving instruction in the following areas: * Precautions needed for ADL care with a dislocated right shoulder (when providing dressing, toileting, and transfer assistance); * Evacuation status and ability; and * Ability to use call system. Resident 1 had a significant change of condition on 01/16/22 related to a dislocated right shoulder. There was no documented evidence Resident 1's service plan had been updated with information related to increased care needs and precautions needed to prevent further injury or discomfort during ADL care. The need to ensure service plans were reflective of the residents' current needs, provided clear caregiving instruction, and were available to staff was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN) and Staff 19 (Regional RN), on 06/07/22. They acknowledged the findings.

1.  The service plans for Residents 1,2,3,4,5 have been reviewed and updated to reflect residents current status. 2.  Remaining resident service plans will be reviewed to confirm that each is reflective of current status.   Resident changes in condition will be discussed during daily staff stand up and reviewed by the clinical team during daily clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record.  As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. All service plans will be readily available to all staff to reflect current care needs.   3.  The Executive Director and/or designee will randomly audit resident service plans twice weekly for 60 days to assure ongoing compliance. 4.  The Executive Director and Licensed Nurse are responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of the care needs and preferences of the resident and provided clear direction regarding the delivery of services for 2 of 2 sampled residents (#s 6 and 7), whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 02/2022 with diagnoses including dementia and was receiving hospice services for end of life care. Resident 1 was observed in bed at all times and relied on staff for all ADL care. Observations of the resident, interviews with staff, review of the current service plan and clinical records, revealed Resident 6's service plan was not reflective of the resident's status, preferences, and did not provide clear directions to staff in the following areas: * Toileting status; * Sleeping preferences; * Hospice services including bathing assistance; * Use of a fall mat; and * Use of an air mattress for pressure relief. On 10/10/22, the service plan was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction. 2. Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia. Observations of the resident, interviews with staff, review of the current service plan and clinical records, revealed Resident 7's service plan was not reflective of the resident's status and did not provide clear directions to staff in the following areas: * Hospice services including bathing assistance; * Use of a fall mat; and * Use of an air mattress for pressure relief. On 10/10/22, the service plan was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the service plan was not reflective of the resident's status and did not provide clear direction.

1.  The service plans for Residents 6 and 7 have been reviewed and updated to reflect resident's current status. 2.  Residents receiving hospice services will be reviewed to confirm that each service plan is reflective of current status. Resident changes in condition will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record.  As part of the routine service plan process, the Licensed Nurse or designee will conduct a record review and obtain feedback from caregivers working directly with the resident prior to updating the service plan. All service plans will be readily available to all staff to reflect current care needs. Routine clinical meetings will be held at least 4 times per week. 3.  The Executive Director or designee will randomly audit three service plans per week for 60 days. 4.  The Executive Director and Licensed Nurse are responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 2 of 2 sampled residents (#s 3 and 5) reviewed for falls.  Findings include but are not limited to: 1. Resident 3 was admitted to the facility in 04/2022 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 3 was observed during the survey to utilize a four wheeled walker independently for mobility. Resident 3's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 3's clinical record revealed the resident was noted to have fallen four times between 04/23/22 and 05/26/22. There was no documented evidence Resident 3's fall interventions were evaluated with each instance and monitored for effectiveness. The need to monitor interventions related to the ongoing falls experienced by Residents 3 was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (regional RN) on 06/07/22 and 06/08/22. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 03/2020 with diagnoses of Alzheimer's disease and dementia and was evaluated to be at risk for falls. Resident 5 was observed during the survey to utilize a wheel-chair independently for mobility. Resident 5's current service plan indicated the resident was a fall risk and provided interventions to reduce falls. Resident 5's clinical record revealed the resident was noted to have fallen seven times between 03/20/22 and 06/06/22. There was no documented evidence Resident 5's fall interventions were evaluated with each instance and monitored for effectiveness. The need to monitor interventions related to the ongoing falls experienced by Resident 5 was reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN) on 06/07/22. They acknowledged the findings.

1. Service plans for 3 and 5 have been reviewed and updated. Resident 3 and 5's fall history have been reviewed and service plan updated to include interventions to address fall risk.   2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record.  Associates will be educated on proper reporting for changes in condition and associated documentation.  Medication Technicians will be educated on the community alert charting policy and associated documentation on 6/23/2022. Licensed nurses educated on the need to monitor interventions related to the ongoing falls experienced by any resident. 3. Resident changes in condition will be discussed during daily staff stand up and reviewed by the clinical team during daily clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation is reflected in the resident record. 4. The Executive Director is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific to evaluated needs and service planned interventions for 1 of 1 sampled resident (# 7) reviewed for falls. This is a repeat citation. Findings include but are not limited to: Resident 7 was admitted to the facility in 05/2015 with diagnoses of dementia and was evaluated to be at risk for falls. Resident 7 was observed during the survey to utilize a wheelchair with escort by staff for mobility. Resident 7's current service plan and temporary service plans indicated the resident was a fall risk and provided interventions to reduce falls. Resident 7's clinical record revealed the resident was noted to have fallen three times between 09/24/22 and 09/25/22. There was no documented evidence Resident 7's fall interventions were evaluated with each instance and monitored for effectiveness. The need to monitor interventions related to the ongoing falls experienced by Resident 7 was reviewed with Staff 1 (ED) and Staff 8 (RCC) on 10/10/22. They acknowledged the findings.

1. Service plans for resident 7 have been reviewed and updated. Resident's fall history have been reviewed and service plan updated to include interventions to address fall risk. 2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Interventions will be assessed to ensure effectiveness and new ones implemented if needed. Med techs will be educated on collection of information at time of falls to aid in root cause analysis and intervention development. 3. Resident incidents will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed and monitored for effectiveness. Appropriate updates will be made to service plans and documentation will be reflected in the resident record. 4. The Executive Director is responsible for this plan of correction and will be in clinical meeting and stand up at least 4 times per week.

Based on observation, interview and record review, it was determined the facility failed to evaluate and monitor residents specific needs and service planned interventions for 1 of 1 sampled resident (# 9) reviewed for falls. This is a repeat citation. Findings include but are not limited to: Resident 9 was admitted to the facility in 09/2020 with diagnoses including dementia. During the acuity interview on 12/21/22, Resident 9 was identified to be at risk for falls. Resident 9 was observed during the survey to require assistance with transfers, and required staff escort in his/her wheelchair. In an interview with Staff 27 (Medication Tech) on 12/21/22, she explained Resident 9 was a fall risk, required assistance with transfers, and was escorted in a wheelchair for mobility. Resident 9's current service plan 12/16/22 and temporary service plans reviewed between 12/8/22 and 12/20/22 noted the resident was a fall risk and provided interventions to reduce falls including frequent checks, pain management, and fall mat for bedside. Resident 9's clinical record revealed the resident had fallen four times between 12/08/22 and 12/20/22. There was no documented evidence Resident 9's fall interventions were evaluated with each fall and monitored for effectiveness. The need to monitor interventions related to the ongoing falls experienced by Resident 9 was reviewed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 8 (RCC) on 12/21/22. They acknowledged the findings.

1. Service plans for resident 7 have been reviewed and updated. Resident's fall history has been reviewed and service plan updated to include interventions to address fall risk. Interventions and root cause analysis will be conducted to ensure personalized care plan and interventions related to each individual incident. 2. Resident records for those with a known pattern of falls will be reviewed to assure proper evaluation, preventative measures and documentation included in the resident record. Interventions will be assessed to ensure effectiveness and new ones implemented if needed. Med techs will be educated on collection of information at time of falls to aid in root cause analysis and intervention development. 3. Resident incidents will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed and monitored for effectiveness. Appropriate updates will be made to service plans and documentation will be reflected in the resident record. 4. The Executive Director is responsible for this plan of correction and will be in clinical meeting and stand up at least 4 times per week.

2. Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia. Observations of the resident from 06/06/22 to 06/08/22 revealed the resident required staff assistance with incontinent care and was in bed at all times. During the survey, Staff 9 (MT/CG) reported the resident had an overall decline in status in 05/2022 in the following areas: * Was no longer ambulating with a walker, was in bed at all times; and * Was needing additional staff assistance with meal intake, showers, personal hygiene, and bladder and bowel management. The multiple changes represented a significant change of condition. There was no documented evidence the facility RN conducted an assessment of the resident's overall decline which included findings, a description of the resident status, and interventions made as a result of the assessment. The failure to conduct an RN assessment following a significant change in status was discussed with Staff 1 (ED) on 06/08/22. She acknowledged the findings. 3. Resident 5 was admitted to the facility in 03/2022 with diagnoses including Alzheimer's disease. Resident 5 was observed during the survey to get up for the day between 10:00 am and 11:00 am, and eat in the dining room with staff assistance. Resident 5's weight record was reviewed during the survey and revealed the following: * 01/14/22 - 103 pounds; * 01/24/22 - 97 pounds; * 02/21/22 - 94.4 pounds; * 04/11/22 - 95.9 pounds; and * 04/18/22 - 89.2 pounds. From 01/14/22 to 01/24/22, Resident 5 had lost 6.0 pounds or 5.8 % of his/her body weight, and from 04/11/22 to 04/18/22, s/he had lost 6.7 pounds or 6.98% of his/her body weight, which represented a significant weight loss. Resident 5's 05/24/22 service plan indicated the resident required physical assistance while eating and would benefit from finger foods. The facility began administering  boost high protein supplement three times daily on 12/22/21. The 06/01/22 - 06/08/22 MAR indicated the supplement had not been provided on two occasions at 08:00 am because the resident was sleeping. On 04/18/22, Staff 2 (RN) conducted an assessment of the resident's weight loss, however, did not address if the current interventions were evaluated and monitored for effectiveness. On 06/08/22, the need to ensure the facility RN completed assessments of significant changes of condition, including reviewing interventions for effectiveness, was discussed with Staff 1 (ED). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a timely assessment of significant changes of condition by a facility RN which documented findings, resident status, and interventions made as a result of this assessment, and failed to update the service plan for 3 of 3 sampled residents (#s 1, 4 and 5) who were reviewed with significant changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia. During the acuity interview on 06/06/22 the resident was identified with an injury to the right shoulder. The clinical record, including the current service plan dated 05/05/22, progress notes dated 12/26/21 through 06/06/22, and temporary care plans, were reviewed during the survey. On 01/16/22 an emergency room after visit summary indicated Resident 1 had a dislocated right shoulder. This represented a significant change of condition. The facility RN documented an assessment of the change of condition on 01/16/22 however, the assessment failed to document the resident's increased care needs with dressing, toileting, ambulation, transfers and precautions needed to prevent further injury or discomfort during ADL care. The need to ensure significant changes of condition were assessed timely by a facility RN which documented findings, resident status and service plan updates as a result of the assessment was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22 They acknowledged the findings.

1.  The records of Residents 1, 4 and 5 have been reviewed and updated as it relates to their significant change of condition. 2.  All residents will be reviewed in order to identify any resident in need of a change of condition assessment by the RN.  Associates will be educated on proper reporting for changes in condition and associated documentation.  Resident changes in condition will be discussed during routine staff stand up and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed, appropriate updates are made to service plans and documentation of RN assessment is reflected in the resident record. Staff stand up and routine clinical meeting will occur at least five times per week. 3.  The Executive Director and/or designee will randomly audit resident records weekly for 60 days to assure ongoing compliance. 4.  The Executive Director & Registered Nurse will be responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 1 of 2 sampled residents (# 4) who was receiving services from outside providers. Findings include, but are not limited to: Resident 4 was admitted to the facility in 01/2018 with diagnoses including dementia and was receiving hospice services. A review of Resident 4's clinical record identified the following hospice recommendations were not implemented: * 05/06/22 -  "Please reposition in bed if [s/he] allows..."; * 05/08/22 - staff to clean and moisturize the resident's mouth every shift; and * 05/20/22 - discontinue non-essential medications including a thyroid hormone medication. There was no documented evidence the recommendations were communicated to staff, made part of the resident's service plan, or implemented. On 06/07/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the findings.

1. The records of Resident 4 have been reviewed and service plan updated to include recommendations made by outside provider as appropriate. Education was provided to staff related to following recommendations and service plan related TSP's that should be processed from third party provider notes. 2. Outside provider notes will be reviewed daily in conjunction with the triple check order process during the clinical meeting to assure actions are taken as necessary. 3.  The Executive Director and/or designee will randomly audit coordination of care notes/documentation weekly for the next 60 days then quarterly thereafter for ongoing compliance. 4.  The Executive Director and Health & Wellness Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 2 of 2 sampled residents (#s 6 and 7) who were receiving services from outside providers. This is a repeat citation. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 02/2022 with diagnoses including dementia and was receiving hospice services. A review of Resident 6's clinical record identified hospice left directions for facility staff to administer a PRN bowel medication on 10/04/22. There was no documented evidence the recommendations were communicated to staff or implemented. On 10/10/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the findings. 2. Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia and was receiving hospice services. A review of Resident 7's clinical record identified the following hospice recommendations were not implemented: * 09/15/22 - "Please use reclining [wheelchair] footrests to help prevent sliding.", and * 09/25/22 - "Continue fall precautions - bed in lowest position and fall mat on floor. Please check on [patient] frequently [every 1 to 2 hours]." There was no documented evidence the recommendations were communicated to staff, made part of the resident's service plan, or implemented. On 10/10/22, the need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (ED) and Staff 8 (RCC). They acknowledged the findings.

1. The records of Resident 6 and 7 have been reviewed and service plan updated to include recommendations made by outside provider as appropriate. Education was provided to staff related to following recommendations and service plan related TSP's that should be processed from third party provider notes. 2. Outside provider notes received in the last 30 days will be reviewed to ensure all recommendations have been implemented as appropriate. Outside provider notes will be reviewed daily in conjunction with the triple check order process during the clinical meeting to assure actions are taken as necessary. 3.  The Executive Director and/or designee will audit coordination of care notes/documentation during clinical meetings to ensure proper implementation from outside providers. 4.  The Executive Director and Health & Wellness Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure medication orders were carried out as prescribed for 1 of 5 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to: Resident 1 was admitted in 2021 with diagnoses which included hypertension and dementia. A review of the clinical record identified the following signed physician orders were not administered as prescribed: * Isosorbride Mononitrate (for Hypertensive chronic kidney disease) once daily, to be held if systolic blood pressure was below 110. The MARs, reviewed from 05/01/22 through 06/05/22, revealed five occasions when Resident 1's systolic blood pressure was under 110 and the medication was not held. * Omeprazole ordered for 40 mg once daily (for gastro-esophageal reflux disease) was being administered as 20 mg once daily. The need to ensure physician orders were administered as prescribed was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22. They acknowledged the findings.

1.  The physician orders and MAR/Diet Orders for Resident 1 have been reconciled to assure accuracy.   2. Medication Technicians will be trained on following; physician orders, ancillary order entry, and the triple check review process for new orders.  Transcription will be reviewed by the Health & Wellness Director or designee in conjunction with the daily clinical meeting. Quarterly MAR review process has been updated to reflect needs for accurate medication orders. 3. The Executive Director and/or designee will conduct random physician order audits weekly for 60 days to assure ongoing compliance.  Thereafter audits will be conducted quarterly in conjunction with the service planning/chart review process.    4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given only for specific medical symptoms and only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 5) who was administered a PRN psychoactive medication. Findings include, but are not limited to: Resident 5 was admitted to the facility in 03/2020 with diagnoses including Alzheimer's disease. Resident 5's record indicated s/he had orders for PRN Ativan for "mild agitation and anxiety". Resident 5's 06/01/22 through 06/08/22 MAR was reviewed during the survey and revealed the following: * The PRN Ativan was administered on five occasions; * The MAR lacked clear instructions to non-licensed staff regarding how the resident demonstrated signs and symptoms of agitation or anxiety : * No non-drug interventions were developed for staff  to attempt prior to administering the psychoactive medication; and * No document evidence non-drug interventions had been attempted with ineffective results prior to administering the medication. On 06/07/22 Resident 5's record was reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN) who acknowledged the findings.

1. PRN parameters have been reviewed for resident 5 with non pharm interventions in place to use prior to administering psychotropic medication. 2. Staff educated on policy of using non pharm interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR. Remaining residents with orders for as needed psychotrophic medication has been completed. Parameters, common side effects and non-pharmacological interventions have been added to the resident's medication record where needed. Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation. 3.  Executive Director, Health & Wellness Director  and/or designee will randomly audit PRN's orders weekly for 60 days then monthly thereafter for compliance.   4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure PRN psychoactive medications were given  only after non-drug interventions had been attempted and were ineffective, for 1 of 1 sampled resident (# 7) who was administered a PRN psychoactive medication. This is a repeat citation. Findings include, but are not limited to: Resident 7 was admitted to the facility in 05/2015 with diagnoses including dementia. Resident 7's record indicated s/he had orders for: * PRN Ativan for anxiety; and * PRN Haloperidol for agitation. Resident 7's 10/01/22 through 10/10/22 MAR was reviewed during the survey and revealed Resident 7 was administered both medications on 10/02/22. There was not documented evidence non-drug interventions had been attempted with ineffective results prior to administering the psychoactive medications. On 10/10/22 Resident 7's record was reviewed with Staff 1 (ED). She acknowledged the findings.

1. Med tech education was provided on 10/11/2022 for proper documentation on using non pharmacological interventions prior to administering medication. 2. Med techs will have ongoing education and reminders of policy for using non pharmacological interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR. 3. Executive Director & Health and Wellness Director will review Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation and follow up with med techs. 4.  Executive Director is responsible for compliance.

Based on interview and record review, it was determined the facility failed to ensure resident specific reasons for use of PRN psychoactive medications were documented and given only after non-drug interventions had been attempted and were ineffective, for 2 of 3 sampled resident (#s 8 and 9) who were administered PRN psychoactive medications. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 04/2016 with diagnoses including dementia. Resident 8's record indicated s/he had orders for Haldol 0.5 mg as needed for behaviors and anxiety. Resident 8's 12/01/22 through 12/21/22 MAR was reviewed and revealed Resident 8 was administered the medication on six occasions. There was no resident-specific parameters or specific reasons for the use of the psychotropic medication for Resident 8. There was no documented evidence non-drug interventions had been developed and attempted with ineffective results prior to administering the psychoactive medications. 2. Resident 9 was admitted to the facility in 09/2022 with diagnoses including dementia. Resident 9's record indicated s/he had orders for Lorazepam 0.5 mg as needed for agitation and anxiety. Resident 9's 12/01/22 through 12/21/22 MAR was reviewed and revealed Resident 9 was administered the medication on two occasions. There was no resident-specific parameters or specific reasons for the use of the psychotropic medication for Resident 9. There was not documented evidence non-drug interventions had been developed and attempted with ineffective results prior to administering the psychoactive medications. On 10/10/22, Resident 8 and 9's records were reviewed with Staff 1 (ED) and Staff 3 (Health and Wellness Director LPN). They acknowledged the findings.

1. Med tech education was provided on the day of survey for proper documentation on using non pharmacological interventions prior to administering medication. RN educated on proper PRN administration parameters and how to input in eMAR system. 2. Med techs will have ongoing education and reminders of policy for using non pharmacological interventions prior to administering psychotropic medications. Staff educated on how to properly document this in eMAR. 3. Executive Director & Health and Wellness Director will review Psychotropic medication orders and administration will be reviewed during the routine clinical meeting for appropriate documentation and follow up with med techs. 4.  Executive Director is responsible for compliance.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 240.

Z142 Refer to C240

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 240.

Z142 Refer to C240

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 C 240.

Refer to C240.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 260, C 270, C 280, C 290, C 303 and C 330.

Z162 Refer to C 260, C 270, C 280, C 290, C 303 and C 330.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 260, C 270 and C 290.

Z162 Refer to C 260, C 270, C 290 and C 330.

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 270 and C 330.

Refer to 270 and C330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 1 of 5 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2021 with diagnoses including dementia, diabetes, and urinary tract infections.   Resident 1's service plan, dated 05/05/22, indicated a carbohydrate-controlled diet and providing D-Mannose supplement with water, both of which had been discontinued by the physician in previous months. The service plan lacked an individualized nutrition and hydration plan, including information related to the resident's food and fluid preferences and need for increased fluids. The need to develop individualized service plans addressing residents' nutrition and hydration needs and preferences was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN) and Staff 19 (Regional RN), on 06/07/22 They acknowledged the findings .

1. Orders for resident 1 have been updated and are accurate. Individualized nutrition and hydration plan was added to resident 1 service plan. 2. Nutrition and Hydration plans will be added for each resident and will be personalized based on their individual needs. 3. Executive Director and Health and Wellness Director will review all service plans to ensure accurate personalized nutrition and hydration plans every week for 60 days. 4. Executive Director will be responsible for compliance.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 5 of 5 sampled residents (#s 1, 2, 3, 4 and 5) whose service plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 3, 4 and 5's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and individualized activity plans included in their service plans including: * Residents' past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and * Identified activities for behavior interventions. There was no specific activity plan which detailed what, when, how, and how often staff should offer and assist each resident with individualized activities. On 06/07/22 and 06/08/22, the need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director), Staff 19 (Regional RN), and Staff 20 (Program Coordinator). They acknowledged the findings.

Individualized Activity Plans 1. Individualized activity plans will be added to residents 1, 2, 3, 4 and 5. 2. Program Manager will meet with Health and Wellness Director to evaluate each resident and create individualized activity plans for every resident to meet the needs of each resident. 3. Executive Director and Health and Wellness Director will review resident's activity plans weekly to ensure accuracy and ongoing compliance. 4. Executive Director and Program Manager will be responsible for compliance.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#1) with documented behaviors. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2021, with diagnoses including dementia and major depressive disorder. Resident 1's progress notes documented the following: * 04/20/22, "Agitated behavior and delusional thinking"; and * 04/21/22, "[S/he] got very angry with the male staff accusing and refusing care from them. Towards the end of the night [s/he] calmed down." During an interview with Staff 21 (CG) on 06/07/22, it was reported Resident 1 experienced hallucinations of seeing things on the floor, other people in his/her room and accusations that "we are doing things to other residents." Staff 21 also reported Resident 1 hit her while she was trying to calm him/her down. Staff 21 stated "I don't know of anything that helps to calm [him/her] down." The resident's current service plan did not address the major depressive disorder or hallucinations, and lacked individualized interventions to assist staff in minimizing the negative impact of these behaviors. The need to include an individualized behavior plan for residents with behavioral symptoms was discussed with Staff 1 (ED), Staff 3 (Health and Wellness Director LPN), and Staff 19 (Regional RN) on 06/07/22. They acknowledged the findings.

Individualized Behavioral Plans 1. Individualized behavioral plan has been added to resident 1's care plan. 2. Program Manager will meet with Health and Wellness Director to evaluate each resident and create individualized behavior plans for residents that exhibit behavioral symptoms. 3. Executive Director and Health and Wellness Director will review resident's behavioral plans weekly to ensure accuracy and ongoing compliance. 4. Executive Director and Program Manager will be responsible for compliance.

Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240, C 260, C 270, C 290, C 330, Z 142 and Z 162.

C455 Refer to C240, C260, C270, C290, C330, Z142, Z162

Based on observation, interview, and record review, it was determined the facility failed to ensure their relicensure 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, C 270, C 330, Z 142, and Z 162.

Refer to C240, C270, C330.

The findings of the re-licensure survey, conducted 06/06/22 through 06/08/22, 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 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 first revisit to the re-licensure survey of 06/08/22, conducted on 10/10/22, 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 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 re-licensure survey of 06/08/22, conducted on 12/21/22, 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 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 third revisit to the re-licensure survey of 06/08/22, conducted 04/13/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.