Brookdale River Valley Tualatin

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 OARs 333-150-0000. Findings include, but are not limited to: On 06/11/26 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Drains under two-sink prep area and between stove and deep fat fryer – black matter build up; * Commercial stand mixer – food splatters on splash guard; * Robot coupe and blender bases – food debris/sticky; * Stainless steel wall between cooking equipment and prep counter – streaks of grease drips/splatters; * Lower shelf below 2 and 3 sink prep counter – debris/spills; * Interior of ice maker – build up of pink/black matter; * Shelves below coffee maker – build of food debris/spills; * Shelves in front of service line – spills/drips/food debris; * Side of convection oven – drips/spills; * Wall behind deep fat fryer – grease drips; * Floor between deep fat fryer and stove – significant build up of black matter/grease/debris; * Shelves above cooking equipment – greasy/sticky; * Interior of refrigerator on service line used for storage – bottom shelf significant amount of food debris/crumbs; * Dishwashing area wall underneath counter – black/brown matter build up/caulking on dirty side – black matter build up; * Cart stored next to ice maker – top and bottom shelves with spills/splatter/debris; and * Wall above spray hose sink between ice maker and juice machine – yellow matter/black matter build up on caulking. Improper food storage included: * Freezer – packages of vegetables and meat products without opening dates; * Containers with mini marshmallows and cocoa mix – scoops/spoons in product; * Bulk food containers under prep counter – lids not securely covered/cups in cornmeal and sugar; * Containers of ground coffee next to coffee maker – open to air with no lids in place; * Dry storage open bulk food bins containing bags of rice, flour, split peas, sugar – bags not securely closed to prevent contamination; * Bags of panko, brown sugar, lentils on top of bins/shelves in dry storage area - not securely closed; and * Open bags of muffin mix, dry cereal, dry pasta in dry storage – not labeled with date opened. Other areas of concern included: * Commercial stand mixer – not covered when not in use; * Colored cutting boards – worn and scored; and * Several staff not wearing hair restraints. The areas of concern were discussed with and acknowledged by Staff 1 (Chef/Person In Charge) on 06/11/26 at 12:45 pm and discussed with and acknowledged by Staff 2 (Associate Executive Director) and Staff 3 (Business Office Manager on 06/11/26 at 1:00 pm.

Staff retrained on policy kitchen sanitation on 06/19/2026. The following findings were addressed with deep cleaning on 06/19/2026. Additional findings which required new/replacement items or maintenance addressed below with compliance date. * Drains under two-sink prep area and between stove and deep fat fryer-black matter build-up. * Commercial stand mixer- food splatters onn splash guard. * Robot coupe and blender bases-food debris/sticky * Stainless steel wall between cooking equipment and prep counter- streaks of grease drips/splatters * Lower shelf below 2 and 3 sink prep counter- debris/spills * Interior of ice maker-build-up of pink/black matter. * Shelves in front of service line-spills/drips/food debris. * Side of convection oven- drips/spills. * Wall behind deep fat fryer-grease drips. * Floor between deep fat fryer and stove- significant build-up of black matter/grease/debris. * Shelves above cooking equipment-greasy/sticky. * Interior of refridgerator on service line used for storage- bottom shelf significant amount of food debris/ crumbs. * Dishwashing area wall underneath counter- black/brown matter build-up/ caulking on dirty side-black matter build-up. Work order in place for Maintenance to re-caulk area. Caulking to be completed by compliance date of 08/10/2026. * Cart stored next to ice maker-top and bottom shelves with spills/splatter/debris. * Wall above spray hose sink between ice maker and juice machine-yellow matter/black matter build-up on caulking. Work order in place for Maintenance to re-caulk area. Caulking to be completed by compliance date of 08/10/2026. The following findings were addressed on 06/19/2026 with staff retraining on proper handling/serving/storing of food items, use of scoops and use of open dates on open items. * Freezer- packages of vegetables and meat products without opening dates: Open dates applied to open packages. * Containers with mini marshmellows and cocoa mix-scoops/spoons in product * Bulk food containers under prep counter-lids not securely covered/cups in cornmeal and sugar. * Containers of ground coffee next to coffee maker-open to air with no lids in place. * Dry storage open bulk food bins containing bags of rice, flour, split peas, sugar-bags not securely closed to prevent contamination. * Bags of panko, brown sugar, lentils on top of bins/shelves in dry storaage area-not securely closed. * Open bags of muffin mix, dry cereal, dry pasta in dry storage- not labled with date opened. * Commercial stand mixer-not covered when not in use: Cover in use. Staff retrained on application of cover on 06/19/2026. * Colored cutting boards-worn and scored: Replacement colored cutting boards ordered by Dining Manager on 06/17/2026. * Several staff not wearing hair restraints: Staff retrained on hair net use on 06/19/2026. Dining Manager reviewed and revised cleaning schedule and task assignments to add identified areas of concern on 06/19/2026. Dining staff will complete updated assignments as designed with no end date. Dining Manager or designee will review staff cleaning assignment completion weekly with no end date. Dining Manager or designee will monitor use of hair nets daily with no end date. Dining Manager or designee will complete kitchen sanitation audit 1 time a week for 30 days and then monthly with no end date. Dining Manager or designee will track and trend kitchen sanitation audit/ observation and present trends with action plan to Quality Assurance review monthly for 90 days or until consistent compliance is met. Executive Director or designee will inspect and monitor kitchen sanitation through monthly Quality Assurance reviews for 90 days and quarterly with no end date.

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.

Refer to plan of correction for C240.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

Based on interview and record review, it was determined the facility failed to ensure the initial evaluation contained all required elements specified in the rule and quarterly evaluations described the resident’s physical health status for 2 of 5 sampled residents (#s 2 and 3) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into to the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. Review of the resident’s move-in evaluation indicated the following elements were not addressed: * Routines: eating and bathing; * Cultural preferences and traditions; * Grooming ability; * Transfer ability; and * Non-pharmacological interventions for pain. The information lacking from the move-in evaluation was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. The resident's quarterly evaluation, dated 11/14/25, was reviewed, and staff were interviewed. The evaluation was not reflective of his/her current physical health status in the following areas: * Transfer status; * Pain, including pharmacological and non-pharmaceutical interventions; and * Skin condition. The need to ensure the quarterly evaluation was reflective of the resident’s current physical health status was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged.

Resident #3 Routines and non-pharmacological interventions for pain were reviewed with resident on 1/20/26 Resident #2 evaluation was reviewed and updated with current physical health status to include pharmacological and non-pharmaceutical interventions 1/20/26 Current resident evaluations will be reviewed and updated by 3/09/26 Associates who complete the evaluations at move in and after were educated on the form and policy on 1/23/26 Health and Wellness Director or designee will monitor the move in and scheduled evaluations for person centeredness during weekly collarborative care review with no end date Executive Director or designee will monitor completion of audits 3 times a month for 60 days. Health and Wellness Director or designee will review plan of correction at monthly quality assurance for 180 days.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation (1) INITIAL SCREENING AND MOVE-IN. (a) The facility must determine whether a potential resident meets the facility's admission requirements. (b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability. (c) Each resident record must, before move-in and when updated, include the following information: (A) Legal name for billing purposes. (B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding: (i) Name. (ii) Pronouns. (iii) Gender identity. (C) Prior living arrangements; (D) Emergency contacts; (E) Service plan involvement - resident, family, and social supports; (F) Financial and other legal relationships, if applicable, including, but not limited to: (i) Advance directives; (ii) Guardianship; (iii) Conservatorship; and (iv) Power of attorney. (G) Primary language; (H) Community connections; and (I) Health and social service providers. (2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule. (a) Resident evaluations must be: (A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and (B) Performed at least quarterly, to correspond with the quarterly service plan updates. (C) Reviewed and any updates must be documented each time a resident has a significant change in condition. (D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident. (E) Documented, dated, and indicate who was involved in the evaluation process. (b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations. (3) EVALUATION REQUIREMENTS AT MOVE-IN. (a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in. (b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in. (c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs. (d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility. (e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation. (4) QUARTERLY EVALUATION REQUIREMENTS. (a) Resident evaluations must be performed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff. (d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained. (5) The resident evaluation must address the following elements: (a) For service planning purposes, if indicated by the resident, (A) Name. (B) Pronouns. (C) Gender identity. (b) Resident routines and preferences including: (A) Customary routines, such as those related to sleeping, eating, and bathing; (B) Interests, hobbies, and social and leisure activities; (C) Spiritual and cultural preferences and traditions; and (D) Additional elements as listed in 411-054-0027(2). (c) Physical health status including: (A) List of current diagnoses; (B) List of medications and PRN use; (C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and (D) Vital signs if indicated by diagnoses, health problems, or medications. (d) Mental health issues including: (A) Presence of depression, thought disorders, or behavioral or mood problems; (B) History of treatment; and (C) Effective non-drug interventions. (e) Cognition, including: (A) Memory; (B) Orientation; (C) Confusion; and (D) Decision-making abilities. (f) Personality, including how the person copes with change or challenging situations. (g) Communication and sensory abilities including: (A) Hearing; (B) Vision; (C) Speech; (D) Use of assistive devices; and (E) Ability to understand and be understood. (h) Activities of daily living including: (A) Toileting, bowel, and bladder management; (B) Dressing, grooming, bathing, and personal hygiene; (C) Mobility - ambulation, transfers, and assistive devices; and (D) Eating, dental status, and assistive devices. (i) Independent activities of daily living including: (A) Ability to manage medications; (B) Ability to use call system; (C) Housework and laundry; and (D) Transportation. (j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort. (k) Skin condition. (l) Nutrition habits, fluid preferences, and weight if indicated. (m) List of treatments - type, frequency, and level of assistance needed. (n) Indicators of nursing needs, including potential for delegated nursing tasks. (o) Review of risk indicators including: (A) Fall risk or history; (B) Emergency evacuation ability; (C) Complex medication regimen; (D) History of dehydration or unexplained weight loss or gain; (E) Recent losses; (F) Unsuccessful prior placements; (G) Elopement risk or history; (H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and (I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan. (p) Environmental factors that impact the resident's behavior including, but not limited to: (A) Noise. (B) Lighting. (C) Room temperature. (6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference. Stat. Auth.: ORS 410.070, 441.122, 443.450 Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans provided clear direction regarding the delivery of services for 1 of 1 sampled resident (# 5) who resided in the memory care unit. Findings include, but are not limited to: Resident 5 moved into the memory care unit in 07/2025 with diagnoses including dementia. The resident's clinical record was reviewed, interviews were completed with staff, and observations were made. The service plan did not provide clear direction to staff in the following areas: * Showers pertaining to when the resident required full assistance, stand-by assistance, and when Resident 5 requested additional showers; * Bathroom assistance and when it was needed; * How the resident exhibited behaviors and direction to staff on what precautions to take; * Increased fall risk when Resident 5 exhibited behaviors; * Ability to communicate needs and wants; * Dressing assistance needs and the use of underwear or briefs; and * Personal preference of assistance with hair brushing. The need to ensure service plans provided clear direction regarding the delivery of services was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 1:24 pm. They acknowledged the findings.

Service plan for resident # 5 was reviewed and updated with person centered instruction and interventions on 1/21/26 Service plans will be reviewed and updated for person centered instruction by 3/09/2026 Associates who create service plans received additional training on person centered approach and behavioral supports on 1/16/2026- 1/23/2026 Additional Service plan reviews will be completed during weekly collaborative care reviews Executive Director or designee will audit completion three (3) times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days

OAR 411-054-0036 (1-4) Service Plan: General (1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan. (2) SERVICE PLAN. The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence. (a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations. (b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services. (c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided. (d) Changes and entries made to the service plan must be dated and initialed. (e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed. (f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative. (g) The facility administrator is responsible for ensuring the implementation of services. (h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements. (3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN. (a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident. (b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences. (c) Staff must document and date adjustments or changes as applicable. (4) QUARTERLY SERVICE PLAN REQUIREMENTS. (a) Service plans must be completed quarterly after the resident moves into the facility. (b) The quarterly evaluation is the basis of the resident's quarterly service plan. (c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused to consent to an order for 3 of 3 sampled residents (#s 2, 3, and 5) with documented medication refusals. Findings include, but are not limited to: 1. Resident 5 moved into the memory care unit in 07/2025 with diagnoses including hypertension, atrial fibrillation, and dementia. The resident's 12/01/25 through 01/05/26 MARs and 09/24/25 physician's orders were reviewed. The records showed that Resident 5 refused medications on the following days: * 12/21/25: Amiodarone (for heart failure), carvedilol (for hypertension), vitamin D (supplement), furosemide (for blood pressure), potassium (supplement), apixaban (for atrial fibrillation), and buspirone (for anxiety); and * 12/28/25: Atorvastatin (for cholesterol), carvedilol, irbesartan (for hypertension), memantine (for Alzheimer's disease), apixaban, and buspirone. On 01/06/26 at 12:25 pm, Staff 11 (Director of Clinical Services) confirmed the physician was not notified of the 12/21/25 and 12/28/25 medication refusals. The need to notify the physician or other practitioner when a resident refused to consent to an order was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 on 01/08/26 at 1:24 pm. They acknowledged the findings. 2. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension The resident's 12/01/25 through 01/05/26 MARs and progress notes and temporary service plans dated 10/05/25 through 01/05/26 were reviewed and revealed the resident refused to consent to orders for the following medications: * Gabapentin 300mg capsule at bedtime for neuropathic pain on three occasions; * Trazodone 50mg tablet at bedtime for trouble sleeping on three occasions; * Acetaminophen 500mg, take 2 tablets two times a day for pain, on three occasions; * Carboxymethylcellulose 0.5% eye drops twice a day for eye irritation on three occasions; and * Nystatin mouth/throat suspension 100000 unit/ml four times a day for infection of oropharynx on 19 occasions. There was no documented evidence the prescriber was notified after each refusal of the medications. In an interview on 01/07/26 at 10:00 am, Staff 7 (Health and Wellness Coordinator) acknowledged the lack of provider notification and stated they are continuing to educate MTs to write progress notes and fax the provider for each refusal. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged. No further documentation was provided. 3. Resident 3 moved into the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident’s MAR, dated 12/01/25 to 01/05/26, was reviewed, and the following was noted: * The resident was prescribed acetaminophen 500 mg tablet – two tablets TID for pain; * The MAR indicated the resident refused the medication 21 of 93 times it was to be administered; and * There was no documented evidence the facility notified the prescriber of the refusals. The need to ensure the facility notified the physician or other practitioner if the resident refused consent to an order was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings.

Physician contacted for resident 2, 3, 5 for refusal trends on 1/20/2026. Upon receipt of physican review, orders will be updated Medication Tech and nurses trained on physician notification policy and resident rights on 1/20/2026 Medications refusals will be reviewed to verify notifications per physican order will be completed in clinical review at least 5 days a week for 3 months Health and Wellness Director or designee will track and trend pattern of refusals and notify physician for medication need and/or expected notification Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (1)(j-k) Systems: Resident Right to Refuse (j) The resident or the person legally authorized to make health care decisions for the resident has the right to consent to, or refuse, medications and treatments.(k) The physician or other practitioner must be notified if a resident refuses consent to an order. Subsequent refusals to consent to an order will be reported as requested by the prescriber.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

Based on observation, interview, and record review, it was determined the facility failed to keep an accurate MAR for all medications that were ordered by a legally-recognized provider and administered by the facility for 3 of 5 sampled residents (#s 1, 2, and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 moved into the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident’s MARs, dated 12/01/25 through 01/05/26, were reviewed, and the following was noted: The resident had orders from the hospice provider for PRN haloperidol (for hallucinations and agitation), PRN lorazepam (for anxiety or difficulty breathing), and PRN morphine (for pain and difficulty breathing). Each medication order included instructions that the facility “May give without trying nonpharmacological interventions first.” The morphine order had additional instructions to “Call hospice if ineffective or if patient receives [three] hourly doses.” * The instructions were not transcribed to the MAR for the three medications noted above. The need to ensure the MAR was accurate was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings. 2. Resident 1 moved into the facility in 07/2023 with diagnoses including fibromyalgia, chronic pain, chronic fatigue syndrome, and constipation. The resident’s MAR, dated 12/01/25 to 01/05/26, was reviewed, and the following was noted: There was no documented evidence of medication-specific instructions for administration of the following PRN medications by unlicensed staff: * Metoprolol succinate ER (extended release) 25mg (for atrial fibrillation); * Flecainide acetate 100mg (for atrial fibrillation); and * Denta 5000 plus dental cream 1.1%. In an interview with Staff 11 (Director of Clinical Operations) on 01/07/26, she confirmed that there were no medication-specific orders for the three medications. The need to ensure that medication-specific instructions were included with each medication was discussed with Staff 1(ED), Staff 2 (Associate ED), Staff 3, Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:05 pm. They acknowledged the findings. 3. Resident 2 moved into the facility in 07/2022 with diagnoses including dementia, depression, and hypertension. The resident's 12/01/25 through 01/05/26 MARs and current physician orders were reviewed, and the following inaccuracies were noted: On 12/20/25, a treatment for Resident 2’s pressure ulcer was added to the MAR which directed MTs to complete during the evening shift. On 01/07/26 at 3:10pm, Staff 13 (MT) acknowledged she had never performed the resident’s treatment. On 01/07/26 at approximately 3:15pm, Staff 18 (CG), confirmed that she had performed the treatment for the resident on several occasions. A review of the resident’s MAR showed the treatment was initialed by Staff 13 on 11 occasions. The need to ensure MARs were initialed by the person who completed the treatment was discussed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:25 pm. The findings were acknowledged.

Electronic Medication Administration Record ( EMAR) reviewed for resident 1: instructions were verified and transcribed to the medication administration record for the three medications noted on 1/08/26 and 1/21/26 Resident 2, treatment orders were reviewed and verified with instruction on 1/09/26 Resident 3, hospice orders were verified and transcribed to medication administration record on 1/21/26 EMAR accuracy and documentation will be reviewed, clarified and corrected as needed by 2/13/2026. Medication Technition and Nurses were trained on the policy for medication administration documentation, PRN administration on 1/20/2026 Nurse or designee will reconcile written physician orders in conjuction with order transcription review process during clinical review at least 5 days a week for 3 months. Executive Director or designee will monitor audit completion 3 times a month for 60 days. Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (2) Systems: Medication Administration (2) MEDICATION ADMINISTRATION. An accurate Medication Administration Record (MAR) must be kept of all medications, including over-the-counter medications that are ordered by a legally recognized prescriber and are administered by the facility.(a) Documentation of the MAR must be completed using one of the following processes. An alternative process may be used only with a written exception from the Department.(A) The MAR may be signed as the medications are set-up or poured. Medications must not be set-up in advance for more than one administration time. If a medicine cup or other individual container is used to set-up the medications, it must be placed in a closed compartment labeled with the resident's name. Changes to the MAR that occur after the medication is delivered, must be documented by the same staff person who administered the medication.(B) The facility may choose to sign the MAR after the medication is administered to a specific resident and prior to the next resident-specific medication or treatment.(b) MEDICATION RECORD. At minimum, the medication record for each resident that the facility administers medications to, must include:(A) Current month, day and year.(B) Name of medications, reason for use, dosage, route and date and time given.(C) Any medication specific instructions, if applicable (e.g., significant side effects, time sensitive dosage, when to call the prescriber or nurse).(D) Resident allergies and sensitivities, if any.(E) Resident specific parameters and instructions for p.r.n. medications.(F) Initials of the person administering the medication.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 1 of 1 sampled resident (#1) who was reviewed for self-administration of medications. Findings include, but are not limited to: Resident 1 moved into the facility in 07/2023 with diagnoses including fibromyalgia, chronic pain, chronic fatigue syndrome, and constipation. Resident 1's signed physician orders, dated 09/03/25, and MAR, dated 12/01/25 through 01/05/26, were reviewed during the survey and indicated the following: * During the MAR review, it was discovered that the resident was prescribed the following medications and administering them him/herself, as indicated by “unsupervised self-administration” noted on the MAR for each medication: - Miralax Oral Powder 17gm/scoop (for constipation); - Vit D3 oral capsule 1000 units (a supplement); - Lubiprostone oral capsule 8mcg (for Parkinson’s related constipation); - Colace oral capsule 100mg (for constipation); - Senna oral tablet 8.6mg (for constipation); and - Zinc oral tablet (a supplement). * There was no documented evidence the facility had obtained signed written orders of approval for the resident to self-administer the medications. During an interview with Staff 3 (Health and Wellness Director) on 01/05/26, she confirmed that there was not an order for self-administration of medications. There was no documented evidence that self-medication evaluations were being completed on a quarterly basis. The evaluations provided were completed on 03/26/25 and 01/05/26. The need to ensure residents who choose to self-administer their medications were evaluated quarterly and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medication was discussed with Staff 1(ED), Staff 2 (Associate ED), Staff 3, Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 2:05 pm. They acknowledged the findings.

Self Administration evaluation completed for resident 1 on1/5/26 An audit for the other residents who self-administer medication was completed on 1/20/2026 Associates who complete self-administration audits were trained on policy on 1/23/2026 Service plan team will review required evaluation forms during care conference for completion Health and Wellness Director or designee will audit completion of quarterly evaluations per service plan schedule or changes in condition during collaborative care review weekly for 90 days Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (5) Systems: Self-Administration of Meds (5) SELF ADMINISTRATION OF MEDICATION.(a) Residents who choose to self-administer their medications must be evaluated upon move-in and at least quarterly thereafter, to assure ability to safely self-administer medications.(b) Residents must have a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications.(c) Residents able to administer their own medication regimen may keep prescription medications in their unit.(d) If more than one resident resides in the unit, an evaluation must be made of each person and the resident's ability to safely have medications in the unit. If safety is a factor, the medications must be kept in a locked container in the unit.(e) Unless contraindicated by a physician or resident evaluation, residents may keep and use over-the-counter medications in their unit without a written order.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of the facility.

Based on interview and record review, it was determined the facility failed to ensure PRN psychotropic medications, administered to treat a resident's behavior, must have written, resident-specific parameters, for 1 of 1 sampled resident (#3) who was administered PRN psychotropic medications. Resident 3 was admitted to the facility in 12/2025 with diagnoses including Alzheimer’s disease, type 2 diabetes mellitus, and history of diverticulitis. The resident had orders from the hospice provider for: * PRN haloperidol (for hallucinations and agitation); and * PRN lorazepam (for anxiety or difficulty breathing). There were no parameters for unlicensed staff which described how Resident 3 exhibited hallucinations, agitation, and anxiety to guide the staff in administering the medications. The need to ensure PRN psychotropic medications to treat a resident's behavior had written, resident-specific parameters was reviewed with Staff 1 (ED), Staff 2 (Associate ED), Staff 3 (Health and Wellness Director), Staff 10 (Regional Director of Operations), and Staff 11 (Director of Clinical Services) on 01/08/26 at 12:45 pm. They acknowledged the findings.

Review of residents on PRN psychotropic medications was completed on 1/09/2026 and 1/20/26 Diagnosis clarification and/or individualized parameters will be completed by 1/31/2026 Associates were trained on PRN medications and treatment policy on 1/20/2026 PRN Psychotropics and other PRN medications orders will be reviewed during clinical review at least 5 days a week for three months. Executive Director or designee will monitor audit completion 3 times a month for 60 days Health and Wellness Director or designee will review plan of correction at monthly quality assurance review for 180 days.

OAR 411-054-0055 (6) Systems: Psychotropic Medication (6) PSYCHOTROPIC MEDICATION. Psychotropic medications may be used only pursuant to a prescription that specifies the circumstances, dosage and duration of use.(a) Facility administered psychotropic medications may be used only when required to treat a resident's medical symptoms or to maximize a resident's functioning.(b) The facility must not request psychotropic medication to treat a resident's behavioral symptoms without a consultation from a physician, nurse practitioner, registered nurse, or mental health professional. This does not apply when a resident is enrolled in a hospice program as defined in OAR 333-035-0050.(c) Prior to requesting a psychotropic medication, the facility must demonstrate through the evaluation and service planning process that non-pharmacological interventions have been attempted.(d) Prior to administering any psychotropic medications to treat a resident's behavior, all direct care staff administering medications for the resident must know:(A) The specific reasons for the use of the psychotropic medication for that resident.(B) The common side effects of the medications.(C) When to contact a health professional regarding side effects.(e) When a psychotropic medication is ordered by a health care practitioner other than the resident's primary care provider, the facility is responsible for notifying the resident's primary care provider of that medication order within 72 hours of when the facility was notified of the order. This includes weekends and holidays. Notification may be either by telephone or electronic submission and should be documented by the facility.(f) Medications that are administered p.r.n. that are given to treat a resident's behavior must have written, resident-specific parameters.(A) These p.r.n. medications may be used only after documented; non-pharmacological interventions have been tried with ineffective results.(B) All direct care staff must have knowledge of non-pharmacological interventions.(g) Psychotropic medications must not be given to discipline a resident, or for the convenience of 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: Please refer to: C 260 and C 305.

Refer to plan of correction for C252, C260, C305, C310, C325, and C330.

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, conducted during a site visit on 07/03/25, the facility's failure to develop, maintain, and implement an Acuity-Based Staffing Tool (ABST) was substantiated for 1 of 2 sampled residents (#1). Findings include, but are not limited to: In separate interviews, Staff 1 (Administrator) stated the following: * The facility used a proprietary ABST called "Service Alignment;" * The tool was separated by "assisted living" and "memory care;" * The tool reported staffing hours in total minutes per 24 hours; * The posted staffing plan was built off the ABST. A review of the facility's proprietary ABST indicated the need for 5,970.51 staffing minutes for the "assisted living." A review of the facility's posted staffing plan for the "assisted living" indicated it was not built off the ABST, for a total of 5,400 minutes: * Day: four direct care staff and two medication aides; * Evening: two direct care staff and two medication aides; * Night: one direct care staff and one medication aide. Additionally, observation and interviews indicated discrepancies in the ABST profile for Resident 1 for the following ADLs: * Personal hygiene; * Grooming; * Transfering; * Repositioning; * Eating; and * Monitoring for physical conditions or symptoms. The findings were reviewed with and acknowledged by Staff 1 via electronic communication on 07/30/25. The facility's failure to develop a staffing plan for each shift, that meets the scheduled and unscheduled needs of all residents, was substantiated.

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 OARs 333-150-0000. Findings include, but are not limited to: On 04/09/25 at 10:45 am, the facility kitchen was observed to need cleaning in the following areas: * Vents and surrounding ceiling area between cooking equipment and service line – heavy build up of dust; * Drain and flooring underneath two sink counter – significant build up of debris/black matter; * Hood vents above cooking equipment – build up of grease/dust; * Piping between convection oven and flat top grill – heavy build up of dust/grease; * Oven doors and handles – sticky/drips/spills; and * Backsplash on dirty side of dishwashing area and wall underneath dishwashing sink counter – build up of black matter. Other areas of concern included: * Colored cutting boards – finish worn/scored (potentially uncleanable). * Some staff lacked use of hair and beard restraints. The areas of concern were observed and discussed with Staff 1 (Dining Services Manager) and discussed with Staff 2 (Executive Director) on 04/09/25. The findings were acknowledged.

Ceiling venting and surrounding areas between cooking equipment and service line was cleaned was assessed by Mainteance on 4/16/25 and scheduled for repair and cleaning for 4/18/25____ Drain and flooring underneath two sink counter was cleaned on _4/15/25____ Hood vents above cooking equipment was assessed by mainteance on 4/16/25 Staff trained on how to clean Piping between convection oven and flat top grill on_4/17/25__ Oven doors and handles was cleaned on_4/10/25__ Backsplash on dirty side of dishwashing areas wall and under sink was cleaned on_4/10/25__ Color cutting boards purchased on 4/15/25 Staff retrained on hair net use on 4/09/25 and 4/15___ Staff retrained on policy kitchen santitation on 4/17/25 Dining Manager or designee reviewed and revised cleaning schedule and task assignments to add identified areas of concern on 4/13/25 Dining staff will complete updated assignments as designed with no end date Dining Manager or designee will review staff cleaning assignent completion weekly with no end date Dining Manager or designee will complete kitchen santitation audit at least 1 time a week for 30 days and then monthly with no end date Dining Manager or designee will submit maintenance work orders that require maintenance or vendor intervention at time identified Dining Manager or designee will track and trend kitchen sanitation audit/observation and present trends with action plan to Quality Assurance review monthly for 90 days or until consistent compliance is met. Executive Director or designee will inspect and monitor kitchen sanitation through monthly quality assurance reviews for 90 days and quarterly thereafter with no end date.

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.

Ceiling venting and surrounding areas between cooking equipment and service line was assessed by Maintenance on 4/16/25 and scheduled for cleaning and repair 4/18/25____ Drain and flooring underneath two sink counter was cleaned on _4/15/25____ Hood vents above cooking equipment was cleaned on 4/16/25 Staff trained on how to clean Piping between convection oven and flat top grill on_4/17/25__ Oven doors and handles was cleaned on_4/10/25__ Backsplash on dirty side of dishwashing areas wall and under sink was cleaned on_4/10/25__ Color cutting boards purchased on 4/15/25 Staff retrained on hair net use on 4/09/25 and 4/15___ Staff retrained on policy kitchen santitation on 4/17/25 Dining Manager or designee reviewed and revised cleaning schedule and task assignments to add identified areas of concern on 4/13/25 Dining staff will complete updated assignments as designed with no end date Dining Manager or designee will review staff cleaning assignent completion weekly with no end date Dining Manager or designee will complete kitchen santitation audit at least 1 time a week for 30 days and then monthly with no end date Dining Manager or designee will submit maintenance work orders that require maintenance or vendor intervention at time identified Dining Manager or designee will track and trend kitchen sanitation audit/observation and present trends with action plan to Quality Assurance review monthly for 90 days or until consistent compliance is met. Executive Director or designee will inspect and monitor kitchen sanitation through monthly quality assurance reviews for 90 days and quarterly thereafter with no end date.

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 maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observations of the main kitchen and unit kitchenette was conducted on 12/07/23 from approximately 10:50 am through 1:20 pm and revealed the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Interior of drawers and cabinets; * Interior and exterior of range/ovens and grill; * Grill flat top; * Fan cage and ceiling of walk-in cooler; * Interior of plate warmer; * Metal rack storing canned goods; * Multiple open stainless steel shelves; * One utility cart; * Cobwebs on the interior and exterior of two sets of windows and ceiling corners; * Flooring thresholds, corners, edges, between, under and behind equipment; and * Multiple areas on walls throughout. b. Multiple metal racks in the walk in cooler were rusted and/or worn to bare metal. c. Scoops were found stored in food item bins/containers. d. Multiple ready to eat food items stored in kitchen area and in the walk-in cooler were uncovered and exposed to potential contamination. e. Food items delivered from the previous day were stored on the floor in the dry storage area. f. Two meals consisting of vegetables, stuffing, and chicken were pureed together for residents with modified diets. Staff 3 (Sous Chef) reported she didn't have time to puree the items separately. The meal was not considered palatable. g. Kitchens staff and servers were not consistently wearing aprons. At approximately 1:20 pm on 12/07/23 the above areas were discussed and reviewed with Staff 1 (Executive Director) and Staff 2 (Dining Services Director). They acknowledged the findings.

Unit Kitchenette interior and exterior cabinets were cleaned and sanitized on 12/7/2023 Unit Kitchenette interior and exterior range/ovens cleaned on 12/7/2023. staff retrained 12/28/23 Grill flat top cleaned on 12/8/23 * Fan cage and ceiling of walk-in cooler were cleaned -12/12/23 * Interior of plate warmer cleaned on 12/7/23 and will be convered to prevent accumalation of debris * Metal rack storing canned goods cleaned 12/12/23 * Multiple open stainless steel shelves- cleaned 12/8/23 * One utility cart cleaned on 12/7/23 * Cobwebs on the interior and exterior of two sets of windows and ceiling corners;- cleaned on 12/8/23 window clean, window sill painted, and air conditioner removed. 12/12/23 * Flooring thresholds, corners, edges, between, under and behind equipment- Cleaned on 12/8/23. retrained 12/28/23 Multiple metal racks in the walk in cooler were rusted and/or worn to bare metal.- Shelving ordered 12/29/23 and will be replaced. Metal shelves organized and cleaned 12.22.23 Scoops were found stored in food item bins/containers.- removed 12.7.23/ staff inserviced.  Staff  retrained 12.28.23 Multiple ready to eat food items stored in kitchen area and in the walk-in cooler were uncovered and exposed to potential contamination.- Items removed on 12.7.23 staff retrained on 12.28.23 and 12.29.23 Food items delivered from the previous day were stored on the floor in the dry storage area- Items moved on 12.7.23, staff retrained on  12.8.23 and 12.28.23 f. Sous Chef and staff trained on modified diet preperation on 12.7.23 and 12.28.23. g. Kitchens staff and servers trained on wearing aprons Corrected 12/7/23- staff retrained on_12.28.23 ___ Policy and procedures for food sanitation, preparation, modified diets,  cleaning schedules/sanitation checklist, cross contamination, equipment maintenance, labeling, pest control, satellite kitchen, storage of perishable food reviewed with dining staff on_12.28.23 Dining staff received additioanl training on preparation of modified diets, palatable and presentation on_12/28/23 Dining staff will complete  updated food safety and sanitation assignments per daily, weekly, and monthly schedule with no end date Dining Manager or designee will review dining staff assignment completion weekly with no end date Dining Manager or designee will complete full Food Safety and Sanitation audit at least 1 times a week for 30 days and then monthly with no end date Dining Manager or designee will monitor modified diet preparation and presentation prior to serving  daily for 30 days or until consistency is met and then during monthly audits. Dining Manager or designee will track and trend food safety and sanitation audits and present action plant for Quality assurance review monthly for 90 days or until consistent compliance is met. Executive Director or designee will inspect and monitor compliance with food preparation, food safety and sanitation through monthly quality assurance reviews for 90 days and quarterly thereafter with no end date.

The findings of the kitchen inspection, conducted 12/07/23, 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 revisit to the kitchen inspection of 12/07/23, conducted on 03/05/24, are documented in this report. It was determined the facility was in compliance with OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview and record review, conducted during a site visit from 10/18/23 to 10/19/23,  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 for 2 of 2 sampled residents (#s 6 and 7). Findings include, but are not limited to: The facility's posted staffing plan indicated the need for the following staff: RCF: Day: 3 CG, 2 MT; Evening: 2 CG, 2 MT; and Night: 2 CG, 1 MT. Memory Care: Day: 2 CG, 1 MT; Evening: 2 CG, 1 MT; and Night, 1 CG, 1 MT. 2 MT and 1 CG were observed working in the RCF portion on the facility on day shift 10/19/23. A review of the facility's staff schedules for October 2023 revealed the facility is not consistently staffed to their posted staffing plan. During an observation and interview on 10/19/23, Resident 6 waited 52 minutes for a response to his/her call light. A review of Resident 6's call light logs for the prior 30 days revealed at least 11 other incidences when s/he waited over 25 minutes for his/her call light to be answered. During an interview on 10/19/23, Resident 6 stated sometimes s/he has to wait so long to get assistance that s/he soils his/herself before staff arrive. A review of Resident 7's call light logs for the prior 30 days revealed at least 4 occasions when s/he waited over 25 minutes for a call light to be answered. During an interview on 10/18/23, the Compliance Specialist was notified of an incident on night shift in June 2023 when a single staff member was working in the locked memory care portion of the facility and the building's smoke alarms went off, causing the exit doors to remain unlocked. Staff 5 stated that all residents were woken up and that s/he was left to care for all memory care residents alone, and was unable to monitor both exit doors at the same time. One exit door leads to the street. The findings were reviewed with and acknowlegded by Staff 1 (Executive Director) and Staff 12 (RN). 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. Verbal plan of correction: Staffing had been a focus since new ED started. They have a brand new RCC, 10/19/23 was her first day shadowing. Hiring is ongoing. They have updated job postings, offering sign-on bonus and referral bonus. The facility just hired two new caregivers that will start training on the floor that week and just hired another CG the morning of 10/19/23. ED emailed a sister facility to see if they have anyone who needed extra hours. They had a couple people out on leave.

Based on interview and record review, conducted during a site visit from 10/18/23 to 10/19/23, it was confirmed the facility failed to ensure that staff have sufficient communication and language skills. Findings include, but are not limited to: During the site visit on 10/19/23, Compliance Specialist attempted to interview Staff 6 (CG) who was unable to understand and answer the questions asked in English. An incident investigation dated 10/09/23 stated "Appears to be a language barrier [with Staff 6] as evidence by interviewer need to repeat and explain questions." The findings were reviewed with and acknowledged by Staff 1 (Executive Director) and Staff 12 (RN) on 10/19/23. It was confirmed the facility failed to ensure that staff have sufficient communication and language skills. Verbal plan of correction: During hiring process now they do their best to verify that individuals speak and understand English. RN now responsible for interviewing care staff. Former RCC spoke Spanish and would interview staff in Spanish if needed and hire them. Facility stated they would implement oversight of Spanish-speaking staff to ensure they were able to communicate with residents and would review facility's tuition-reimbursement program if staff want to take English classes.

The findings of the on-site investigation, conducted 10/18/23 through 10/19/23 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 observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 11/15/22 through 11/18/22, 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 deficiencies in report.

C150 Refer to plans of correction for the following citations:  C200, C231, C240, C252, C260, C262, C270, C280, C295, C302, C325, C340, C370, C372, C374, C420, C422, C999 (C160), Z142, Z155, Z162, Z165, Z168

Based on observation, interview and record review the facility failed to ensure residents were treated with dignity and respect, were free from verbal abuse and had a safe and home-like environment. Multiple residents expressed concerns and distress related to known resident behaviors which occurred in the common areas. Resident 13 experienced verbal and physical abuse from Resident 12. The findings include, but are not limited to: 1. Resident 13 moved into the facility in 04/2021 with a diagnosis of dementia. During the acuity interview on 11/15/22, the resident was identified as being in a relationship with Resident 12. Observations, staff interviews and Resident 13's service plans and progress notes were reviewed during the survey. In an interview on 11/18/22, Staff 34 (Lead Receptionist) stated Resident 12 was verbally aggressive with staff and at times with Resident 13. During a group interview on 11/16/22, seven residents reported , Resident 12 and 13's negative interactions were "abusive and hard to watch when you can't do anything about it" and Resident 12's "obsessive" behaviors, which included taking multiple salt shakers, coffee cups and other utensils from the dining room tables and "constantly" going into the kitchen, caused each of them distress while trying to eat meals in the dining room. A review of Resident 13's service plan, dated 07/29/22, indicated "'[S/he] enjoys [gender] resident [Resident 12] in community and often see in each other room alone or spent the night [sic]." A review of Resident 13's evaluation, dated 08/03/22, indicated "Can have difficulty on the days [his/her] [gender] friend does not remember [him/her]. [S/he] does not want to be alone and gets sad sometimes crys [sic] when [s/he] is not wanting to spend time with [him/her]." A review of Resident 13's progress notes indicated the following: * 07/25/22 Resident 13 was taken to MCC per ED/nurse due to [his/her] [gender] friend having some aggressive behaviors." Resident 13 returned to the assisted living on 07/27/22; * 07/31/22 "Resident came down to 2nd floor from being in [Resident 12's] room all upset and almost in tears due to [Resident 12] calling this resident mean names like A-hole, B**ch and this MT asked if [Resident 12] put hands on [him/her] and [S/he]stated no but this resident was only wearing briefs and a shirt"; * 08/09/22 "resident came out of [his/her] room @ 9:55 pm with just a shirt on and nothing else saying [S/he] wanted a [male/female] out of her house [Resident 12's room number]."; * 08/13/22 "[Resident 13] had a disagreement with [Resident 12] today close to meal time and was seen leaving [his/her] room at 1705 with tears in [his/her] eyes. [S/he] stated [s/he] had a fight with [him/her] and did not want to discuss it and was going to [his/her] own room." Resident 13 didn't attend the evening meal and was unable to be located within the facility. Resident later was found on the first floor hallway. Staff reported s/he was "hiding", needed to be alone and declined to eat in the dining room that evening; * 08/26/22 Resident 13 came out of Resident 12's room naked and became angry when redirected by the CG; * 08/27/22 Resident 13 was emotional and crying; and * 11/11/22 Resident 13 was convinced that some man pushed him/her against the wall and s/he fell.   The facility failed to ensure all residents were treated with dignity and respect and failed to ensure Resident 13 was free from neglect, verbal and physical abuse, and had a safe home-like environment. On 11/18/22 at 11:39 am, the survey team requested an immediate plan of correction to ensure Resident 13 was free from verbal and physical abuse, all residents were treated with dignity and respect and had a safe home-like environment. An immediate plan of correction was received and approved by the survey team on 11/18/22 at 3:13 pm. The situation was abated. The need to ensure residents' were free from neglect and abuse and received care and services in a home-like environment was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22.  They acknowledged the findings. 2. Resident 12 moved into the facility in 02/2022 with diagnosis of vascular dementia. During the acuity interview on 11/15/22, the resident was identified as being in a relationship with Resident 13. Observations, staff interviews and a review of Resident 12's service plans and progress notes were reviewed during the survey. In an interview on 11/17/22, Staff 30 (CG) relayed witnessing Resident 12 have multiple instances of verbal aggression and obsessive behaviors while in the dining area of the facility, and reported Resident 12's behavior was disruptive to other residents in the dining area. Staff 30, also reported hearing Resident 12 exhibit verbal aggression towards Resident 13. Staff 30 reported on 11/08/22 someone in Resident 12's unit pulled the call light. When staff arrived, Resident 12 became verbally aggressive towards staff and Resident 13. Staff 30 reported staff spent 30 minutes attempting to calm Resident 12 down and eventually removed Resident 13 from the unit, while Resident 12 continued "yelling" after them. On 11/18/22, observations of breakfast meal service in the dinning room noted Resident 12 and 13 were dining together. Resident 12 had four coffee cups on the dining room table. Resident 12 was seen sliding the four coffee cups toward Resident 13. Resident 13 waved [his/her] hands to decline the coffee cups. Resident 12 appeared confused and insisted Resident 13 take the cups. A review of Resident 12's progress notes indicated the following: * 07/24/22 staff observed Resident 13 grab Resident 12's wrist because Resident 12 did not want Resident 13 to leave the building. When Resident 12 let go of Resident 13's wrist, the CG and family helped "sneak" [Resident 13] out the side door so s/he could leave; * 07/31/22 Resident 12 became "verbally abusive" when Resident 13 was in his/her room; and * 11/11/22 Resident 12 became "physical with two of the caregivers" when staff were trying to assist [Resident 13]. A review of Resident 12's service plan and temporary care plans lacked documented evidence of the above negative interactions which had occurred between the two residents and lacked staff monitoring instructions and interventions to keep Resident 13 and others safe from Resident 12's physically and verbally aggressive behaviors. The facility failed to ensure all residents were treated with dignity and respect and Resident 13 was free from neglect, verbal and physical abuse, and had a safe home-like environment. On 11/18/22 at 11:39 am, the survey team requested an immediate plan of correction to ensure Resident 13 was free from verbal and physical abuse, all residents were treated with dignity and respect and had a safe home-like environment. An immediate plan of correction was received and approved by the survey team on 11/18/22 at 3:13 pm. The situation was abated. The need to ensure residents' were free from neglect and abuse and received care and services in a home-like environment was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22.  They acknowledged the findings.

1. Resident #13 moved to the community's memory care unit on 11/18/2022.  A temporary service plan was implemented for a smooth transition of her care and to address her separation from resident #12 and the emotional changes that that would bring and address her needs. Resident #12 was evaluated by a geropsychiatric specialist on 11/22/2022. Updates were made to the service plan based on feedback provided. Resident #12 was separated from his partner, resident #13, when she was moved to the memory care unit on 11/18/2022.  A 1:1 caregiver was implemented per safety plan on 11/18/22 to monitor this resident's behaviors and develop interventions.  A temporary service plan was implemented with additional staff monitoring and interventions should resident #12 exhibit any physically or verbally aggressive behaviors. A geropsychiatric specialist visited with resident #12 on 11/22/2022. 2. Staff were provided education  on abuse neglect reporting and resident relationships between 11/18/2022 and 11/21/2022.  Abuse neglect reporting training was conducted by Executive Director to staff on 11/22/2022.  Staff were provided education on resident's Bill of Rights by 12/6/2022.  Residents received copies of Bill of Rights on 12/3/2022 via delivery to their doors.  No other concerning relationships were identified. 3. Residents will continue to receive a copy of resident rights upon move in. Staff will continue to be provided education on resident rights upon hire. Residents' rights concerns will be addressed daily as part of stand up meeting and will be investigated as they arise by Executive Director. Executive Director will host quarterly Town Hall meeting to address resident concerns. 4. Execuive Director and/or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were investigated to rule out abuse and reported to the local SPD when abuse and/or neglect could not reasonably be ruled out for 1 of 1 sampled resident (#5) whose records were reviewed for incidents and injuries of unknown cause. Findings include, but are not limited to: Resident 5 was admitted to the facility on 10/28/2022 with diagnoses including Alzheimer's Disease. Review of the resident's 10/28/22 through 11/12/22 progress notes, incident reports and interviews with staff, revealed the resident was found on the floor on 11/12/22. The resident experienced a laceration to the head.   On 11/12/22, facility staff documented notes related to the injury: "MT asked [him/her] what happened, [he/she] responded I don't know." The facility lacked documented evidence they investigated the injury to reasonably rule about abuse and/or neglect or reported the injury to the local Seniors and Peoples with Disabilities office. The need to reasonably rule out abuse and/or neglect related to injuries of unknown cause was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), and Staff 3 (Area Nursing Manager) on 11/18/22. They acknowledged the findings. Staff 1 was asked to report the injury to the local SPD office on 11/16/22. Confirmation of the report was received the same day.

1. Resident #5's incident was reported to APS on 11/16/2022.   2. Incidents are discussed daily at stand up meeting to ensure investigation is completed timely.  Any incidents without known cause, or otherwise meet reporting criteria will be reported to Adult Protective Services.  Staff received training on abuse/neglect reporting by Executive Director on 11/22/2022.  Community nurses and operations staff received training from contracted RN consultant on abuse neglect reporting and investigations on 11/24/2022. Incidents from the past 30 days will be reviewed. Any incidents determine to meet abuse reporting criteria will be reported to Adult Protective Services. 3. Incidents will be reviewed during routine clinical meeting to monitor effective follow up investigation, and/or APS reporting occurred. Executive Director will regularly review incident reports to determine effective follow up. 4. The Executive Director and/or designee is responsible for this plan of correction.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility consisted of a large kitchen and dining room in the RCF part of the building and a small kitchen and dining room on the secure memory care unit. Food for the MCC was prepared in the large kitchen and transported to the unit to be served. The large kitchen was toured, and meal preparation was observed on 11/15/22 between 10:00 am and 1:00 pm. The MCC kitchen was toured on 11/15/22 at 1:25 pm. Food debris, crumbs, dust/lint, grease build-up, grime and/or dried spills were observed on the following: * The shelf guides, the two coffee makers and the wall behind the coffee/juice counter; * The lower shelves and the top edges of the drawers of the rear prep counter; * The splash guard on the underside of the large stand mixer; * The perimeter and handles of the plastic serving carts; * The wall under the bulletin boards where serving carts were parked; * The lower shelves of the tray line where dinner ware was stored; * The interior silos of the plate warmer; * The handles on the vertical ovens; * The door and handle of the walk-in refrigerator; * Some wire shelves in the walk-in refrigerator; and * The interior of the microwave, the interiors of several base cabinets and outsides of the base cabinet doors in the MCC kitchen. * There was a sconce-shaped bug light on the wall above the handwash sink. Dead insects were hanging on the wall and ceiling above the light and some dead insects had fallen onto the eyewash sink below. * There was dust and lint on a ceiling vent above the steamer and on the ceiling next to the vent. * Two sets of windows had cobwebs and debris on the interior and exterior. The window screens had dust and debris. The front grates of two window air conditioners had black debris build-up. * The grate of a large wall vent in the RCF dining room was covered with dust and debris. The RCF kitchen was toured with Staff 11 (Dining Services Manager) on 11/15/22 at 2:20 pm and the RCF and MCC kitchens were toured with Staff 1 (ED) on 11/16/22 at 11:40 am. Areas needing cleaning were reviewed. Staff 1 and Staff 11 acknowledged the findings.

1. Dining manager and team will complete a deep clean of the kitchen areas noted in statement of deficiencies on or before 12/16/22. 2. The Dietary Manager implemented daily, weekly, and monthly cleaning assignments. Staff will be trained on the cleaning schedules on or before 12/16/22. Staff will  also provided education on how to sumbit work orders for maintenance needs. 3. The Dietary Manager and/or a designee will verify that cleaning schedule is being implemented  through weekly audits. The Executive Director will complete a review of kitchen to monitor cleanliness during routine facility walk through weekly for the next 30 days and monthly thereafter. 4. The Executive Director and Dietary Manager are responsible for this plan of correction

Based on interview and record review , it was determined the facility failed to ensure new move-in evaluations were completed timely and quarterly evaluations were reflective of  the residents' health status and indicated who was involved in the evaluation process for 3 of 7 sampled residents (#s 1, 3, and 5) whose evaluations were reviewed. Findings include, but are not limited to: 1. Resident 5 was admitted to the memory care community on 10/28/22 with diagnoses including Alzheimer's Disease. Review of the resident's move-in evaluation , dated 10/28/22 , revealed the evaluation was signed by Staff 4 (RN). In an 11/16/22 interview, Staff 4 confirmed she signed the evaluation ; however , she reported she was not involved in the evaluation process. In an interview with Staff 3 (Area Nursing Manager) on 11/18/22, she confirmed she had completed the evaluation for Resident 5 but did not document her involvement. The facility failed to have documented evidence indicating who was involved in the evaluation process for Resident 5. The need to ensure evaluations were signed and dated by the person who completed them was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 on 11/18/22. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 10/2022 with diagnoses including chronic embolism of bilateral lower extremity and history of falls. Resident 1's new move-in evaluation consisted of three separate documents, a hand - written paper evaluation, an electronic resident evaluation and a "Resident OR-V2-V2 evaluation." The following deficiencies were noted: * The paper evaluation was not dated or signed to indicated who completed the evaluation; and * The electronic evaluation and Resident OR-V2-V2 evaluations was completed on 10/18/22, four days after move - in. The need to ensure new move-in evaluations were completed prior to move-in and included documentation of who completed the evaluation was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (LPN) and Staff 5 (LPN) on 11/17/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in 03/2018 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD). The most recent evaluation, dated 09/19/22, was not reflective of the resident's current status in the following areas: * Swallowing difficulties; * Perimeter mattress; * Hip pain and interventions; * Use of transfer pole; and * Significant weight gain and interventions. The need to ensure evaluations were reflective of the residents ' current needs and used as a basis for the quarterly service plan was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (LPN) and Staff 5 (LPN) on 11/17/22. They acknowledged the findings.

1. Resident #5's evaluation was completed and documented as to who was involved in the evaluation on 11/18/22. Resident number 1's evaluation was reviewed and completed on 11/18/22.  Resident 1 no longer resides in the community. Resident #3's evaluation was completed on 12/16/22. 2. Resident records will be reviewed to ensure that evaluations are complete and current. 3. Residents will be evaluated before move in, quarterly and upon change of condition. Executive Director or designee will conduct random audits on 5 resident records weekly for the next 60 days to ensure presence and accuracy of evaluation. 4. The Executive Director or designee is responsible for this plan of correction.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of residents' needs, provided clear direction regarding the delivery of services, were completed timely and were readily available to staff, for 8 of 9 sampled residents (#s 1, 2, 3, 5, 6, 11, 12 and 13) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 11 was admitted to the facility in 10/2022 with diagnoses including rectal cancer and irritable bowel syndrome (IBS). The resident's move-in evaluation and referral documents, initial and current service plan (updated 11/14/22) and progress notes were reviewed, and interviews were conducted with a hospice provider, care staff, med techs, facility nurses and the resident. The resident's service plan was not reflective of the resident's current status and lacked instructions for staff in the following areas: * Ability to self-manage incontinence; * Reluctance to accept assistance with hygiene; * Anxiety about running out of toilet supplies; * Assistance with dressing, including donning non-slip socks; * Double portions for meals; and * Frequency with which staff should provide routine checks. The resident's 11/14/22 service plan was not available for staff during the survey. The need to ensure Resident 11's service plan provided adequate information regarding his/her status and care needs, included specific instructions for how staff should provide care and assistance and was available for staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/17/22. They acknowledged the findings. 2. Resident 6 was admitted to the memory care community in 01/2022 with diagnoses including Alzheimer's Disease. During the acuity interview on 11/15/22 the resident was identified for exhibiting negative behaviors. Review of Resident 6's most recent service plan, dated 07/20/22 indicated the following deficiencies: * The service plan was not completed timely (quarterly); and * The service plan did not provide clear instructions to staff, regarding management and redirection for behaviors with negative impact. On 11/18/22 the need to ensure service plans were completed quarterly and provided clear instructions for staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager). They acknowledged the findings. 3. Resident 2 was admitted to the facility in 2017 with diagnoses including congestive heart failure. Review of the most recent service plan , dated 08/14/22, revealed it was not reflective of the resident's needs and lacked clear instruction to the staff in the following areas:   * Emergency evacuation status; * Use of an alternating pressure mattress; and * Ability to use the call light. The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22. They acknowledged the findings. 4. Resident 5 was admitted to the facility on 10/28/22 with diagnoses including Alzheimer's disease. Review of the resident's most recent service plan , dated 11/04/22 , revealed it was not completed timely and was not reflective and lacked clear instruction to the staff in the following areas: * Emergency evacuation status; and * Eating routines. The need to ensure service plans were reflective of resident' needs and included clear direction to staff was discussed with Staff 1 (ED) , Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22. They acknowledged the findings. 5. Resident 1 was admitted to the facility in 10/2022 with diagnoses including chronic embolism and thrombosis of the lower extremity. The resident's move-in evaluation, initial service plan and progress notes were reviewed during the survey. Resident 1 experienced a significant change of condition related to decline in cognition, repeated falls and an increase in ADL care needs on 11/04/22. The service plan was not updated and available to staff , therefore was not reflective of the resident's current status and lacked instructions for staff in the following areas: * Fall interventions; * Behaviors and interventions; * Use of a wheelchair; * Toileting assistance and frequency; and * Cognition status. The need to ensure service plans were reflective of the resident's current status and care needs and provided clear instructions to staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) 11/17/22. They acknowledged the findings. 6. Resident 3 was admitted to the facility in 03/2018 with diagnoses including Chronic Obstructive Pulmonary Disease. Resident 3's current service plan , dated 09/19/22 , was not reflective and lacked clear instructions for staff in the following areas: * Use of a perimeter mattress; * Hip pain and interventions; * Use of transfer pole; * Weight gain and interventions; and * Difficulty swallowing. The need to ensure service plans were reflective of the resident's current status and care needs and provided clear instructions to staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) on 11/17/22. They acknowledged the findings. 7.  Resident 12 was admitted to the facility in 02/2022 with diagnosis including vascular dementia. A review of the service plan , dated 09/22/22, temporary care plans and progress notes identified the service plan was not reflective and lacked clear directions for staff in the following areas: * Relationship status; and * Behaviors, aggression and interventions. The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (ED), Staff 2 (Operations) and Staff 4 (Area Nursing Manager) during the exit interview. They acknowledged the findings. 8. Resident 13 was admitted to the facility in 04/2021 with diagnosis including dementia. A review of the service plan , dated 08/03/22, temporary care plans, progress notes, and incident reports identified the service plan was not reflective and lacked clear directions for staff in the following areas: * Relationship status; * Resident to resident physical altercations; and * Behaviors and interventions. The need to ensure service plans were reflective of the resident's current status and provided clear instructions for staff was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) during the exit interview. They acknowledged the findings.

1. The service plans for Residents 2, 3, 5, 6, 11, 12, and 13 were reviewed and updated by 12/16/22 to reflect current status. Resident 1 has moved out of community. 2. Resident service plans will be reviewed to confirm that each is reflective of current status.   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. Clinical team and/or operations team will utilize service plan calendar to ensure timely completion. 3. The Executive Director and/or designee will randomly audit  5 resident service plans weekly for 60 days to assure ongoing compliance. 4. The Executive Director  and/ or designee is responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team which included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 6 sampled residents (#s 3, 4, 5 and 6) whose service plans were reviewed. Findings include, but are not limited to: The most recent service plans for Residents 3, 4, 5 and 6 were reviewed during the survey. The records lacked documented evidence the service plans were developed by a service planning team. On 11/18/22 the need to ensure service plans were developed by a service planning team was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager). They acknowledged the findings.

1. The service plans for residents 3, 4, 5 and 6 have been reviewed with residents and their families or mailed to families based on individual preference. 2. Service plans will be developed with a service planning team which may include Administrator, dining staff, care staff, other associates of the community and resident and family as applicable. If resident or family declines a care conference they will provided with a paper copy of their service plan. 3. Executive Director and/or designee will conduct random audits of 5 resident service plans weekly to ensure there is evidence of service planning team. 4. The nursing team and Executive Director is responsible for this plan of correction.

5. Resident 11 was admitted to the facility in 10/2022 with diagnoses including rectal cancer and irritable bowel syndrome (IBS). Admission referral documents (a PCP visit note dated 08/05/22) and the facility move-in evaluation noted the resident had been experiencing weight loss and chronic diarrhea. The initial and updated (11/24/22) service plans noted the resident received regular portions for meals as the only information or interventions regarding weight. The facility obtained the resident's weights as follows: * 10/26/22 - (shortly after admission) 117.4 pounds; and * 11/06/22 - 109.6 pounds. Resident 11 lost 7.8 pounds, or 6.65% body weight, in two weeks. The facility failed to monitor the resident consistent with his/her evaluated needs and service plan, given the documented history of and risk for weight loss. There was no documented evidence the facility evaluated the resident's condition and service plan and determined whether additional interventions or monitoring were needed. In an interview on 11/16/22, Staff 11 (Dining Services Manager) reported Resident 11's family had requested directly to her that the kitchen provide double portions. Staff 11 said she tried to provide double portions when possible. In an interview on 11/16/22, Staff 28 (CG) reported she was aware of Resident 11's request for double portions because the resident had told her directly. She said she tried to ensure Resident 11 received double portions. In an interview on 11/17/22, Resident 11 confirmed the family had requested double portions for meals. A current weight was requested for Resident 11. On 11/17/22, Staff 7 (Health and Wellness Coordinator/LPN) reported Resident 11's weight was 111.8 pounds, an increase of 2.2 pounds in less than two weeks. Staff 7 said Resident 11's service plan had recently been updated but acknowledged she was not aware that even though the updated service plan noted the previous weight loss, it lacked any new interventions to address the weight loss or instructions for monitoring the resident. The facility's failure to monitor the resident consistent with his/her evaluated needs and service plan was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/17/22. They acknowledged the facility had failed to address the resident's weight loss. 6. Resident 6 was admitted to the memory care community in 01/2022 with diagnoses including Alzheimer's disease. The resident's service plan, dated 07/20/22, progress notes dated 08/15/22 through 11/14/22, temporary service plans, and incident reports were reviewed. The records indicated Resident 6 experienced two falls in the previous ninety days, listed as: * 10/06/22 - "Housekeeping found [Resident 6] in seated position on floor between bathroom door and room door. Small skin tear found on left side of forehead, and small  scrapes on left side of back. Resident very confused, but no complaints of pain."; and * 10/07/22 - "Staff found [Resident 6] sitting on floor next to [his/her] wheelchair. No injury noted, and no complaints of pain. Resident unable to explain how he got onto floor, but presumed he got out of wheelchair and attempted to walk." Temporary service plans were created for these falls, but lacked resident-specific fall interventions, evidence of new interventions being tried, or evaluation for effectiveness. On 11/18/22 the need to implement resident-specific interventions following changes of condition, and to evaluate those interventions for effectiveness was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager). They acknowledged the findings. No further information was provided. 7. Resident 2 was admitted to the facility in 2017 with diagnoses including Congestive Heart Failure. Review of the resident's TSPs (Temporary Service Plans), hospital discharge paperwork dated 09/23/22 and progress notes dated 08/31/22 through 11/10/22, revealed the hospital diagnosed Resident 2 with a closed fracture of right inferior pubic ramus on 09/26/22. The facility lacked documented evidence the resident's condition was referred to the RN for assessment. The records also indicated the resident experienced the following short-term changes of condition: * 08/20/22 - Bleeding areas on coccyx; * 09/07/22 - Three missed doses of Ipratropium Albuterol nebulizer (shortness of breath); * 09/15/22 - Medication order change, Amoxicillin 500 mg (UTI); and * 10/06/22 - Medication order change, Senna 8.6 mg (bowel care) from routine to PRN. There was no documented evidence the facility determined interventions or actions for the resident's short-term changes of condition, communicated the interventions or actions to staff on all shifts and monitored the conditions with progress noted at least weekly through resolution. Short-term changes of condition and monitoring was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure changes of condition were evaluated and referred to the facility RN if needed, actions and interventions were developed and communicated to staff, changes were monitored, and progress was documented at least weekly through resolution for 7 of 9 sampled residents (#s 1, 2, 3, 6, 11, 12 and 13) whose records were reviewed. Resident 1 experienced a pattern of injury and non-injury falls and unmanaged pain. Resident 12 engaged in repeated incidents of verbal and physical aggression. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including chronic embolism and thrombosis of bilateral lower extremity. a. A review of the resident's initial evaluation and service plan, post-fall evaluations, temporary care plans and progress notes indicated the resident had fallen five times between 10/15/22 and 11/15/22 and had a history of falls prior to moving into the facility. The following incidents were documented: * On 10/24/22 - "resident fell on the floor trying to reach the bathroom and has a skin tear on the left elbow"; * On 11/04/22 - resident's son "requested increased care and we agree based on need"; * On 11/10/22 - resident was on alert for threatening self harm; * On 11/11/22 - "resident is on alert for two falls, once in the AM and once in the evening"; * On 11/12/22 - "resident fell again in the afternoon"; and * On 11/14/22 - resident fell in the bathroom and told staff s/he passed out and had pain in the head and entire left side. The resident was sent to the hospital. Throughout the survey, the resident was observed sitting in a wheelchair in the dining room. Review of the most current service plan, dated 10/18/22, indicated the resident was independent with ambulation with the use of a walker. Review of temporary care plans and post-fall evaluations revealed the following: * There was no evaluation completed after the fall on 10/24/22; and * Subsequent falls on 11/11/22, 11/12/22 and 11/14/22 lacked a review of fall interventions for effectiveness. b. During an observation and interview with Resident 1 on 11/16/22 at 2:30 pm the following was noted: * The resident had an emergency call pendant around his/her neck; however, was unable to show the surveyor how to use the pendant; and * The resident was observed grimacing when repositioning in the recliner. When asked about pain, the resident said yes and touched his/her right lower back, hip and down the right leg. A review of signed physician orders and the MARs dated 10/15/22 through 11/15/22 noted the resident had an order for Tylenol 325 mg, to administer two tablets every 4 hours as needed for pain. There was no documented evidence the facility had administered the pain medication. There was no documented evidence the facility had evaluated the resident's repeated falls and no documented evidence fall interventions had been implemented for any of the falls noted above. There was no documented evidence the facility evaluated or consistently monitored the resident's pain level. The facility's failure to evaluate the resident's repeated falls and pain following each fall, determine and document actions or interventions to potentially decrease the risk of future falls, and to refer to the facility RN for assessment put the resident at risk for repeated falls, unreasonable discomfort, pain and further injury. The need to ensure changes of condition were evaluated and referred to the facility RN if needed, actions and interventions were developed and communicated to staff, changes were monitored, and progress was documented at least weekly through resolution was discussed with Staff 1 (ED), Staff 2 (Operations), Staff 3 (RN), Staff 4 (Area RN Manager), Staff 5 (LPN) and Staff 6 (LPN) on 11/17/22. They acknowledged the findings. 2. Resident 3 moved into the facility in 03/2018 with diagnosis including Chronic Obstructive Pulmonary Disease. A review of progress notes dated 08/03/22 through 11/7/22 indicated the following changes of condition lacked referral to the facility RN if needed, resident-specific interventions and monitoring instructions communicated to staff, and weekly progress noted until the condition resolved: * On 07/12/22 - Significant weight gain; * On 09/18/22 - Significant weight gain; * On 10/07/22 - discontinued multiple medications; * On 10/16/22 - hospital visit; * On 10/25/22 - new order for Oxycodone for pain. A progress note indicated a temporary care plan was in place for monitoring for pain and constipation due to medication use, however staff were unable to provide a copy of a temporary care plan; and * On 11/06/22 - paramedics checked [her/him], but [s/he] didn't want to go out. The need to ensure the facility had a system in place to ensure short-term changes of condition were evaluated and referred to the facility RN if needed, actions and interventions determined and communicated to staff, and weekly progress noted until the condition resolved was discussed with Staff 1 (ED), Staff 2 (Operations), Staff 3 (RN), Staff 4 (Area RN Manager), Staff 5 (LPN) and Staff 6 (LPN) on 11/17/22. They acknowledged the findings. 3. Resident 12 was admitted to the facility in 02/2022 with diagnoses including vascular dementia. A review of the service plan, dated 09/22/22, and progress notes identified the following incidents lacked evaluation, monitoring and resident-specific interventions communicated to staff: * On 07/24/22 - Resident 12 refused to allow another resident to leave the building, grabbed the wrist of the other resident and would not let go; * On 07/25/22 - Resident 12 was having some aggressive behaviors; * On 07/31/22 - Resident 12 called another resident "mean names like A-hole and B**ch"; * On 07/31/22 - "[Resident 12] became verbally abusive toward another resident in his/her room; * On 11/11/22 - Resident 12 became physical with two of the caregivers when they were trying to assist another resident. The failure of the facility to evaluate, monitor and document what action or intervention was needed for the resident resulted in continued verbal and physical aggression towards other residents and staff. On 11/18/22 at 11:39 am, the survey team requested an immediate plan of correction to ensure the resident was evaluated and behavior interventions were developed. An immediate plan of correction was received and approved by the survey team on 11/18/22 at 3:13 pm. The situation was abated. The need to ensure behaviors were evaluated, monitored and resident-specific interventions were developed and communicated to staff and  was discussed with Staff 1 (ED), Staff 2 (Operations), Staff 3 (RN), and Staff 4 (Area RN Manager) during the exit interview. They acknowledged the findings. Refer to C 200, example 2 4. Resident 13 was admitted to the facility in 04/2021 with diagnoses including dementia. A review of the service plan, dated 08/03/22, progress notes, and incident reports noted the following incidents lacked evaluation, resident-specific interventions developed and communicated to staff and  monitoring through resolution: * On 08/13/22 - "hiding from staff and friends"; * On 08/15/22 - on alert for crying and yelling at staff calling them liars; * On 08/23/22 - wandering, emotional and increased confusion; * On 08/26/22 - naked in the hallway and became angry when redirected by the CG; * On 08/30/22 - wandering/emotional/increased confusion; and * On 10/25/22 - resident-to-resident physical altercation with non-sampled resident. The need to ensure behaviors were evaluated, resident-specific interventions communicated to staff and monitored through resolution was discussed with Staff 1 (ED), Staff 2 (Operations), Staff 3 (RN), and Staff 4 (Area RN Manager) during the exit interview. They acknowledged the findings.

1. Resident 1 left the community on 11/24/2022. Records for resident 2, 3, 6, 11, 12, 13 were reviewed and updated accordingly. 2. Resident records for those with a known pattern of falls, behaviors, and or significant weight changes 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 by 12/31/22.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed. Needed updates are made to service plans and documentation is reflected in the resident record. 3. The Executive Director and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance. 4. The nursing team, Executive Director, and/or designee is responsible for this plan of correction.

3.  Resident 16 was admitted to the facility in 07/2022 with diagnoses including dementia and hypertension. Resident 16's 04/04/23 through 05/18/23 progress notes, 05/19/23 service plan and 05/22/23 evaluation were reviewed.  The following changes of condition were noted: a.  Resident 16 was out of the facility for rehabilitation services for approximately 30 days from 03/02/23 through 04/03/23. During interviews with Staff 40 (CG), Staff 33 (Lead MT) and Staff 38 (MT), they stated the resident was independent with ADL care and was confused, used the call light to request help from staff as needed, and required a "little" more assistance since his/her return to the facility. In an interview with Staff 7 (Health and Wellness Director/LPN) on 05/23/23 at 3:15 pm, she stated she had evaluated the resident when s/he was out of the facility and was unable to verify if actions or interventions were developed and communicated to staff related to changes in the resident's level of care. Resident 16 returned to the facility on 04/03/23 and there was no documented evidence actions or interventions were determined and communicated to staff related to the extended stay out of the facility and return from a higher level of care. b.  Resident 16 experienced a change of condition on 04/22/23 related to low blood pressure.   A temporary service plan was generated directing staff to take the resident's vital signs for three days and report to the physician if the blood pressure readings were outside of stated parameters. There was no documented evidence the interventions were implemented nor was there evidence the resident was monitored weekly through resolution. Changes of condition including developing of actions and interventions and monitoring progress until resolution was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager/RN).  Staff acknowledged the findings and no additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure interventions were developed, communicated to staff on each shift and conditions were monitored through resolution for 3 of 6 residents (#s 15, 16 and 17) who experienced short-term changes of condition. This is a repeat citation. Findings include, but are not limited to: 1. Resident 15 moved into the facility in 05/2022  with diagnoses including edema. Resident 15's progress notes dated 03/03/23 through 05/18/23 were reviewed and revealed the following: * On 02/23/23, "Resident stated [s/he was] sitting at the edge of the recliner and started to slide off the chair..."; * On 04/30/23, "Resident was sitting too close to edge of [his/her] recliner and was attempting to readjust in [his/her] chair and slid off the edge of the chair"; and * On 05/12/23, new medication order: mupirocin external ointment 2% (skin infection) apply topically on legs one time a day for three days. There was no documented evidence the facility developed interventions, communicated the interventions to staff on each shift and monitored the changes of condition with progress noted at least weekly through resolution. Short-term changes of condition and monitoring were discussed with Staff 1 (ED) and Staff  3 (Area Nursing Manager/ RN) on 05/25/23. They acknowledged the findings. 2. Resident 17 was admitted to the facility in 02/2023 with diagnoses including diabetes and major depressive disorder. Resident 17's progress notes dated 03/03/23 through 05/23/23 were reviewed and revealed the following: * On 03/03/23 through 03/06/23, missed doses of sertraline (depression) 50 mg tablet  give two tablets one time a day; * On 03/09/23,  Fall with hematoma to scalp; * On 04/10/23,  Fall; and * On 04/19/23, new medication order: oxycodone five mg every six hours PRN for three days only. There was no documented evidence the facility developed interventions, communicated the interventions to staff on each shift and monitored the changes of condition with progress noted at least weekly through resolution. Short-term changes of condition and monitoring were discussed with Staff 1 (ED) and Staff  3 (Area Nursing Manager) on 05/25/23. They acknowledged the findings.

1. Records for residents 15, 16 and 17 were reviewed and updated based on current needs. 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.  Residents with medication changes will be monitored accordingly.  Associates will be educated on proper reporting for changes in condition and associated documentation by 6/21/2023.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed. Needed updates are made to service plans and documentation is reflected in the resident record. 3.       Routine clincial meetings will review open Temporary Service Plans and ensure appropriate measures and documentation are followed through to resolution, with a nurse or designee providing a close to Temporary Service Plans.    3. The Executive Director and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance. 4. The nursing team, Executive Director, and/or designee is responsible for this plan of correction.

4. Resident 11 was admitted to the facility in 10/2022 with diagnoses including rectal cancer and irritable bowel syndrome (IBS). Admission referral documents (a PCP visit note dated 08/05/22) and the facility move-in evaluation noted the resident had been experiencing weight loss and chronic diarrhea. Weight records indicated Resident 11 lost 7.8 pounds, or 6.65% body weight, between 10/26/22 and 11/06/22. Due to the resident's documented history of and risk for weight loss and his/her medical conditions, an RN assessment based on the resident's condition was needed. There was no documented evidence an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment. In an interview on 11/17/22, Staff 4 (RN) stated she was aware of the resident's weight loss, evaluated the resident and believed the initial weight taken had been incorrect. However, she acknowledged she did not document her findings, and the service plan was not updated with any interventions to address the weight loss or monitor the resident. She had not been aware that the resident's family had requested double portions from the kitchen. The need to ensure an RN assessment was completed in accordance with resident condition was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/17/22. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 2017 with diagnoses including congestive heart failure. The resident was bed-bound and required the assistance of two staff members for ADL cares. Review of the resident's 08/31/22 through 11/10/22 progress notes, incident reports and hospital discharge records revealed Resident 2 was found on the floor on 09/26/22. The resident was transported to the hospital. The discharge paperwork from the hospital indicated a new diagoneses of a closed fracture to the right pubic ramus. This constituted a significant change of condition. There was no documented evidence the facility RN completed an assessment of the closed fracture which included findings, resident status, and interventions made as a result of the assessment. In an 11/17/22 interview with Staff 4 (RN) she confirmed an RN assessment had not been completed for Resident 2's injury. The need to ensure the facility RN conducted an assessment of Resident 2's new diagnosis was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 09/28/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for significant changes of condition for 4 of 5 sampled residents (#s 1, 2, 3 and 11) related to significant weight changes, decline in cognition, increase in ADL care, falls, and a fracture. Resident 1 lacked an RN assessment for repeated injury falls, decline in cognition and increase in ADL care. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 10/2022 with diagnoses including chronic embolism and thrombosis of bilateral lower extremity and a history of falls. A review of progress notes indicated the following: * Between 10/15/22 and 11/14/22, the resident had five falls; and * On 11/04/22 a care conference was requested by the resident's son due to "an increase in care needs." During an interview on 11/16/22, Staff 7 (Health and Wellness Coordinator/LPN) reported, "[the resident] has drastically changed since moving in a month ago." In an interview on 11/17/22, Staff 1 (ED) acknowledged the resident's change in care needs related to cognition, mobility and toileting. There was no documented evidence the facility RN completed an assessment which documented findings, resident status and interventions made as a result of the assessment. The lack of an RN assessment and service plan update, which included interventions made as a result of the assessment, resulted in the residents continued falls with injury, and an increase in ADL care needs. The failure to ensure the facility RN completed an assessment for Resident 1's significant changes of condition, which included documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) on 11/17/22. They acknowledged the findings. Refer to C 270 examples 1a and 1b. 2. Resident 3 was admitted to the facility in 03/2018 with diagnoses including Chronic Obstructive Pulmonary Disease (COPD). A review of Resident 3's previous six months of weight records indicated the following: * 03/16/22 - 150.8 lbs.; * There were no documented weights recorded in April and May 2022. * 06/15/22 - 153 lbs.; * 07/12/22 - 169 lbs.; * 08/02/22 - 169.8 lbs.; * 09/18/22 - 171.8 lbs.; and Between 06/15/22 and 07/12/22, Resident 3 gained 16 pounds, or 10.45% total body weight, within one month; Between 06/15/22 and 09/18/22, Resident 3 gained 18.8 pounds, or 10.94% total body weight, within three months; and Between 03/16/22 and 09/18/22 Resident 3 gained 21 pounds, or 13.92 % total body weight, within six months. These weight gains constituted significant changes in condition which required an RN assessment. There was no documented evidence the facility RN completed an assessment which documented findings, resident status and interventions made as a result of the assessment, and there was no documented evidence the service plan was updated. The resident's weight had stabilized from 09/18/22 through 11/05/22. The failure to ensure the facility RN completed an assessment for Resident 1's significant changes of condition, which included documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) 11/17/22. They acknowledged the findings.

1. Resident 1 left the community on 11/24/2022. Records were reviewed by facility RN for resident 2, 3, 11 by 12/16/22. 2. Resident records for those with a known pattern of falls, and/ or significant weight changes 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 by 12/31/22.  Resident changes in condition will be discussed during routine staff stand up meeting and reviewed by the clinical team during routine clinical meeting to assure interventions are developed if needed. Needed updates are made to service plans and documentation is reflected in the resident record. 3. The Executive Director and/or designee will randomly audit 5 resident records weekly for 60 days to assure ongoing compliance. 4. The Executive Director and Registered Nurse will be responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist by 07/01/22, as required in OAR 411-054-0050. Findings include, but are not limited to: In an interview on 11/15/22, Staff 1 (ED) reported she was the facility's designated Infection Control Specialist. Review of Staff 1's infection control training revealed she completed the required Infection Control Specialist training on 11/16/22. The need to ensure the designated Infection Control Specialist completed all required training before 07/01/22 was reviewed with Staff 1 and Staff 2 (District Director of Operations) on 11/18/22. They acknowledged the findings.

1. The Executive Director completed the Infection Control Specialist Training on 11/16/2022 2. The community has identified an additional associate who has complete required training to ensure coverage. 3. The Executive Director or designee will maintain compliance with Infection Control Specialist training as changes in training and guidelines occur.   4. The Executive Director and/or designee is responsible for this plan of correction.

2. Resident 3 was admitted to the facility in 03/2018 with diagnoses including chronic obstructive pulmonary disease and peripheral vascular disease. The resident's 10/01/22 through 11/15/22 MARs, current physician orders, and Controlled Substance Disposition Log entries were reviewed, and staff were interviewed. The following deficiencies were identified: * The resident had a signed physician order for Oxycodone 5 mg, give one tablet, twice daily, as need for pain. * The Controlled Substance Disposition Log noted one tablet was dispensed, however there was no documented evidence on the MAR that the medication was administered. The number of tablets remaining on the medication card matched the number of tablets remaining as indicated in the disposition log. The need to ensure the Controlled Substance Distribution log and residents' MARs matched was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) on 11/17/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure controlled substances were logged and administered accurately for 2 of 2 sampled residents (#s 3 and 8) whose MARs and Controlled Substance Disposition Log were reviewed. Findings include, but are not limited to: 1. Resident 8 was admitted to the facility in 07/2022 with diagnoses including diabetes and alcoholic cirrhosis of the liver. The resident's 10/01/22 through 11/15/22 MARs, current physician orders, and Controlled Substance Disposition Log entries were reviewed, and staff were interviewed. The following deficiencies were identified: * The resident had a signed physician order for Oxycodone 5 mg, two tablets every eight hours as needed for pain. * 10/13/22 - There was an entry for two tablets of oxycodone being removed from the medication card at 7:30 pm, but the entry was crossed out. The resident's MAR indicated two tabs were administered on that date at 7:52 pm. * 10/14/22 - There were two entries in the disposition log at 7:40 pm, each for one tablet of oxycodone. There was no documentation on the MAR to indicate the resident received this administration. * 11/05/22 - The disposition log indicated two tablets were removed from the medication card at 8:00 pm, but the resident's MAR was blank on that date. * 11/13/22 - The disposition log indicated two tablets were removed from the medication card, with no time documented. There was no indication on the MAR the resident received an administration of oxycodone on 11/13/22. The number of tablets remaining on the medication card matched the number of tablets remaining as indicated in the disposition log. On 11/17/22 Staff 9 (RCC) was interviewed at 11:15 am, she indicated she was not sure why the resident's MAR and the Controlled Substance Distribution Log did not match. At 1:55 pm Staff 3 (Area Nursing Manager) reported she did not know why there were discrepancies between the resident MAR and the disposition log. The need to ensure the Controlled Substance Distribution log and residents' MARs matched was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), and Staff 3. They acknowledged the findings. No additional information was provided.

1. Resident 8's and resident 3's Medication Administration Record and controlled substance log have been investigated to include resident interviews. 2. The last 30 days of controlled substance logs as compared to MAR documentation will be completed to assure appropriate documentation as required by 12/31/22. Medication Technicians will receive training on proper eMAR documenation practices when administering controlled substances by 12/31/22.  The Resident Care Coordinator and/or a designee will audit the eMAR and the Controlled Substance Disposition logs 3 times weekly for any inconsistencies in conjunction with the daily clinical meeting. 3. The Executive Director and/or designee will randomly audit controlled substance records weekly for the next 60 days. 4. The nursing team and the Executive Director are responsible for plan of correction and monitoring.

2. Resident 3 was admitted to the facility in 03/2018 with diagnoses including chronic obstructive pulmonary disease and peripheral vascular disease. Observations, interview with staff and an interview with the resident was conducted during the survey. The resident had signed orders for the following medications: * Diclofenac 1% gel (for pain); * Lidocaine 5 % ointment (for pain); and * Miconazole 2 % cream (for rash). Observations on 11/16/22 at 2:35 pm identified the resident had the following topical mediations in his/her bathroom and reported that s/he administered them his/herself, when needed: There was no documented evidence the facility evaluated the resident's ability to safely self-administer the medications and the facility failed to obtain a signed physician order authorizing the resident to self-administer the medications. The need to ensure the facility evaluated all residents who chose to self-administer medications and treatments and obtain signed physician orders authorizing the resident to self-administer medications was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) on 11/17/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure self-administration of medication evaluations were completed quarterly and failed to obtain a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medications for 2 of 2 sampled residents (#s 3 and 7) who self-administered their medication. Findings include, but are not limited to: 1. Resident 7 was admitted to the facility in 02/2021 with diagnoses including major depressive disorder. The resident's current physician orders, service plan, and most recent self-administration evaluations were reviewed, and staff were interviewed. The following was identified: * There was a physician order signed 10/03/22 indicating the resident could self-administered his or her medication. * The resident's service plan indicated s/he self-administered and self-managed all of his/her medications. * The quarterly evaluation received was dated 11/15/22, the day survey entered the facility. Staff 1 (ED) was interviewed on 11/15/22. She stated she would look for a self-administration evaluation dated prior to 11/15/22. At 2:54 pm on 11/15/22, Staff 1 provided a self-administration evaluation for Resident 7 dated 04/03/22. She indicated there were no evaluations to determine the resident's ability to safely self-administrate his/her medications between 04/03/22 and 11/15/22. The need to ensure a resident's ability to safely self-administer medications was re-evaluated quarterly was discussed with Staff 1 and Staff 3 (Area Nursing Manager) on 11/16/22. They acknowledged the findings.

1. Resident 7's self-administration evaluation was completed on 11/15/2022 Resident 3's medications have been removed from her apartment and she is no longer self-administering any medication. 2. An audit of residents who self-administer medications will be completed by 12/31/22 to assure proper orders and self-administration evaluations are on file. Self-medication reviews will be completed as part of service planning process. Staff will be provided education on reviewing resident apartments during routine care and notifying community leadership if medications are present. Residents will be reminded that self medication reviews must be completed for medications in their possession. 3. The Executive Director and/or designee will conduct random audits of 5 resident apartments weekly for the next 60 days 4. The nursing team and Executive Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure the resident's ability to safely self-administer medications for 1 of 2 sampled residents (# 19) who was reviewed for self-administration. This is a repeat citation. Findings include, but are not limited to: Resident 19 was admitted to the facility in 12/2021 with diagnoses including atrial fibrillation, dementia, and Parkinson's disease. During the acuity interview on 05/23/23, Resident 19 was identified as self-administering all his/her medications. That was confirmed by Staff 33 (Lead MT) in an interview on 05/23/23. Review of the records revealed the last evaluation of Resident 19's ability to safely self-administer medications was completed on 04/24/22. In an interview on 05/23/23, Staff 3 (Area Nurse Manager/RN) acknowledged no recent evaluations had been completed, and the evaluation was done by Staff 7 (Health and Wellness Coordinator/LPN) during the survey. The need to ensure residents who chose to self-administer their medications were evaluated at least quarterly to assure resident's ability to safely self-administer medications was reviewed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 on 05/24/23 at 2:45 pm. They acknowledged the findings. No further information was provided.

1.  Resident 19's evaluation was completed on 5/24/2023 2.  An audit of residents who self administer medications will be completed by 6/20/2023 to assure proper orders and self-administration evaluations are on file.  Self-medication reviews will be completed as part of service planning process. 3.  The Executive Director and/or designee will conduct random audits of 5 service plans for self-administration evaluations weekly for the next 30 days. 4.  The nursing team 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 a supportive device with potentially restraining qualities was assessed by an RN, PT or OT prior to use for 1 of 1 sampled resident (#3) who had a perimeter mattress with a metal bar attached at the foot of the bed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 03/2018 with diagnosis including Chronic Obstructive Pulmonary Disease (COPD). On 11/16/22 at 2:35 pm, Resident 3's bed was observed to have a perimeter mattress (a mattress with raised edges) with a metal bar that was placed in a position that limited the resident's ability to move his/her legs around the bar. There was no documented evidence the device with restraining qualities had been assessed by the facility RN, PT or OT, and there was no documented evidence the facility documented other, less restrictive alternatives prior to the use of the device, instructed caregivers on the correct use and precautions related to use of the device and included the use of the device in the resident's service plan. The lack of an RN, PT, or OT assessment for use of a perimeter mattress was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), Staff 4 (RN), Staff 6 (Health and Wellness Coordinator/LPN) and Staff 7 (Health and Wellness Coordinator/LPN) on 11/17/22. They acknowledged the findings.

1. Resident 3's perimeter mattress, transfer pole, and foot cradle have been evaluated by facility RN and updates made to the service plan as appropriate. 2. An audit of residents' apartments will be conducted by 12/31/22 to identify any assistive device in need of evaluation. Any equipment identified will be referred to facility RN for evaluation.   3. The Executive Director and/or designee will review resident equipment and devices upon completion of service plans and as needed should new equipment or devices be implemented for resident care. 4. The nursing team and Executive Director are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff completed infectious disease prevention training prior to 07/01/22. Findings include, but are not limited to: Staff training records were reviewed on 11/16/22. There was no documented evidence Staff 13 (Housekeeper) or Staff 15 (Kitchen Utility) completed infectious disease prevention training by 07/01/22. The need to have had all staff complete infectious disease prevention training by 07/01/22, was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), and Staff 5 (Business Office Manager) on 11/17/22. They acknowledged the findings.

1. Business Office Manager has met with staff 13 and 15 and scheduled them for infection control training on or before 12/31/22. 2. Business Office Manager will conduct an audit by 12/31/22 of current employee files for documentation of training in pre-service topics. Any associates found to be missing infecetion control training will be scheduled for completion by 1/15/22. 3. Business Office Manager has revised the orientation process to include ensuring competion of infection control training prior to being scheduled for on the floor orientation. The Executive Director will review new hire training files for completion for the next 60 days and then conduct random audits thereafter as part of ongong quality assurance. 4. The Executive Director and Business Office Manager are responsible for this plan of correction.

3. In interviews on 11/17/22, caregivers Staff 32, Staff 29 and Staff 30, who asked Staff 29 to translate our interview with her, each stated they thought it would be helpful if resident service plans were provided in Spanish for staff who were primarily Spanish-speaking. In an interview on 11/18/22, Staff 33 (MT) agreed that providing service plans in Spanish would benefit Spanish-speaking staff. When asked, she stated she believed most of the Spanish-speaking staff were unable to read the current service plans. She also explained she had recently begun writing care instructions from Temporary Service Plans (TSPs) in Spanish for the staff. She said, typically, care instructions were communicated to staff verbally due to the language difference. The feedback from the staff was shared with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22. They thanked the surveyor for the feedback. 2a. In an interview on 11/17/22, Witness 1 reported recently asking a housekeeper for the weekly schedule of activities for the unit. Witness 1 stated the housekeeper replied, "I don't speak English." 2b.Witness 1 also reported an incident of hearing a non-sampled facility resident call out, "I think I'm having a heart attack." When the witness arrived to the door of the resident's unit, s/he saw the same housekeeper in the resident's room, cleaning and not responding to the resident's concerns. The witness immediately reported the incident to other facility staff, who then attended to the resident. The facility failed to ensure staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members and health care professionals. The need to ensure facility staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members and health care professionals was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager) on 11/18/22. No further information was provided.

Based on interview and record review, it was determined the facility failed to ensure 3 of 6 newly hired staff (#s 25, 27, and 29) demonstrated competency in all assigned job duties within 30 days of hire and failed to ensure all staff had sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed. Findings include, but are not limited to: 1. Staff training records were reviewed 11/16/22. There was no documented evidence Staff 25 (CG), hired 05/23/22, Staff 27 (CG), hired 07/06/22, or Staff 29 (CG), hired 10/13/22, demonstrated competency in one or more of the following areas within 30 days of hire: * First aid; and * Abdominal thrust. The need to ensure all newly hired staff demonstrated competency in all assigned job duties within 30 days of hire was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), and Staff 5 (Business Office Manager) on 11/17/22. They acknowledged the findings.

1. Business Office Manager. During routine staff training, associates were provided with a written competency exam that was in the same language provided in resident service plans. Associates were able to complete this written exam demonstrating that they were able to read and understand community service plans.   What did we do for the associate identified in the 2567? 2. Business Office Manager will conduct an audit by 12/31/22 of current associate files to determine if skill competency documentation is present as required. All associates found to be missing competency documentation will be retrained with return demonstration observation by 1/17/22. Routine staff training will include written direction and examination to ensure that staff are able to understand language used in resident service plans. Non-direct care staff will be provided education on their responsibility and how to report resident concerns.  New hire staff will receive training with return demonstration by Business Office Manager, Resident Care Coordinator or designee. Staff will not be scheduled for independent work until competency training has been completed. 3. Business Office Coordinator will monitor competencies for compliance and will communicate with clinical leadership when staff are able to be scheduled for independent work after validation that all required competency trainings have been completed. Executive Director will review new employee training files for completion for the next 60 days and then will conduct random audits thereafter as part of ongoing quality assurance. 4. The Executive Director and Business Office Coordinator are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure 2 of 2 long-term staff (#s 17 and 31) completed the required number of hours of annual in-service training, including at least six hours related to dementia care. Findings include, but are not limited to: Staff training records were reviewed 11/16/22. There was no documented evidence Staff 17 (MT), hired 06/18/18, or Staff 31 (CG), hired 02/13/08, completed a minimum of 12 hours of in-service training annually, which included at least six hours of training related to dementia care. The need to ensure staff complete all required annual training hours was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), and Staff 5 (Business Office Manager) on 11/17/22. They acknowledged the findings.

1. An annual inservice calendar was put in place to assure scheduling of 12 hours of annual inservicing for direct care staff to include 6 hours specific to dementia training topics. 2. Executive Director & Business Office Coordinator have been provided education as it relates to requirements in rule.  Business Office Manager will conduct an audit of training files to determine staff in need of annual training hours. Staff will be scheduled to complete all needed inservice hours by 1/17/22.The Business Office Coordinator will routinely monitor completion of on-line training courses as well as track inservice hours provided during all associate meetings. 3. Executive Director and/or designee to audit weekly for 30 days to ensure staff completion of assigned tasks. Will audit monthly for the next 60 days to follow up on staff completion. 4. The Executive Director and Business Office Coordinator are responsible for plan of correction and monitoring.

Based on interview and record review, it was determined the facility failed to consistently provide fire and life safety instruction to staff on alternating months, to consistently conduct unannounced fire drills every other month, and to document all required elements on fire drill documentation, per the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records dated 03/24/22 through 11/02/22 were reviewed on 11/15/22. The following was identified: a. Fire and life safety training was not consistently provided to staff on alternate months. Documentation was provided for staff training on 09/22/22, 07/21/22, 04/21/22, and 03/24/22. b. Fire drills were not consistently completed every other month. Documentation was provided for fire drills in 11/02/22, 09/15/22, and 04/29/22. c. Fire drill documentation did not consistently include one or more of the following required elements: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; and * Evacuation time-period needed. The need to follow all OFC requirements pertaining staff instruction in fire and life safety and fire drills and documentation was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), and Staff 3 (Area Nursing Manager) on 11/17/22. They acknowledged the findings. No additional information was provided.

1. Fire Drill was conducted on 11/2/2022 and is scheduled every month.   2. Moving forward fire and safety drills will be conducted according to company policy, with each shift receiving drill and instruction quarterly. Fire and Safety drill documentation will include evacuation route, problems encountered, and evaution time period needed.These drills will be conducted by Maintenance Director or designee. Maintenance Director will be provided education on conducting drills accoridng to schedule and documentation of required components. 3. The Executive Director will review fire and safety drill documentation monthly to montior for compliance with the required elements. 4. The Executive Director and Maintenance Supervisor are responsible for this plan of correction.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed in fire and life safety topics at least annually, as required by the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records were reviewed on 11/15/22. In an interview on 11/16/22, Staff 10 (Maintenance Manager) reported he believed residents received instruction in fire and life safety annually at town hall or resident council meetings. He stated he did not have any documentation of residents who attended the training. On 11/17/22, Staff 1 (ED) stated in an interview she did not have any documentation of annual training in fire and life safety for residents. The need to provide re-instruction to residents at least annually on fire and life safety topics, in accordance with OFC requirements, was discussed with Staff 1, Staff 2 (District Director of Operations), and Staff 3 (Area Nursing Manager) on 11/17/22. They acknowledged the findings.

1. The Executive Director will be providing fire and life safety instruction to resident during Town Hall meeting scheduled for 12/21/22. Residents will be provide with map showing evacuation route. This map will be posted on the back of the door and resident will sign to showcase understanding. 2. Maintenance Director and Executive Director will be provide training on ensuring residents are provided education on fire and life safety topics a minimum of annually. 3. Maintenance Director  or designee will review that maps remain posted inside resident doors during routine facility walk throughs. 4. The Executive Director and Maintenance Director are responsible for this plan of correction.

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: Please refer to C 150, C 200, C 231, C 240, C 295, C 370, C 372, C 374, C 420 and C 422.

Refer to Plan of Correction for C150, C200, C231, C240, C295, C370, C372, C374, C420, and C422

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: Please refer to C 455

Refer to Plan of Correction for C270 and C325

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 newly hired staff (#s 25 and 27) assigned to work in the memory care community completed all required pre-service orientation and dementia care training and demonstrated competency in assigned duties, and to ensure 2 of 2 long-term staff (#s 21 and 23) completed the required number of hours of annual in-service training. Findings include, but are not limited to: Staff training records were reviewed 11/16/22. 1. There was no documented evidence Staff 25 (CG), hired 05/23/22, or Staff 27 (CG), hired 07/06/22, completed one or more of the following pre-service orientation topics prior to performing any job duties: * Infectious disease prevention; and * Signed job description. 2. There was no documented evidence Staff 25 or Staff 27 completed one or more of the following required 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 ensure safety of residents with dementia, including addressing pain, providing food/fluids, preventing wandering, and use of a person-centered approach; * Environmental factors which 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 which indicate a change in the resident's condition and report behaviors which 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. 3. There was no documented evidence Staff 25 demonstrated competency in general food safety, serving, and sanitation within 30 days of hire. 4. There was no documented evidence Staff 21 (MT), hired 10/14/92, or Staff 23 (CG), hired 09/25/17, had completed the required 12 hours of annual in-service training, to include six hours of dementia care training. The need to ensure new staff completed all required orientation and dementia training, demonstrated competency in all assigned duties within 30 days of hire, and long-term staff completed the required annual training was discussed with Staff 1 (ED), Staff 2 (District Director of Operations), Staff 3 (Area Nursing Manager), and Staff 5 (Business Office Manager) on 11/17/22. They acknowledged the findings.

1. Business Office Manager has met with staff 25 and 7 and has scheduled them to complete infectious disease prevention training and sign job descriptions.  They have also been scheduled to complete Dementia training and food handler's certifications.  An annual inservice calendar is in place to assure scheduling of 12 hours of annual inservicing for direct care staff to include 6 hours specific to dementia training topics.   2. Business Office Manager will conduct an audit by 12/31/22 of current employee files for documentation of training in pre-service topics. Any associates found to be missing pre-service training will be scheduled for online or classroom training to complete all pre-service training by 1/17/22.  Executive Director & Business Office Coordinator have been provided education as it relates to requirements in rule.  The Business Office Coordinator will routinely monitor completion of on-line training courses as well as track inservice hours provided during all associate meetings. 3. Business Office Manager has revised the orientation process to include ensuring that classroom and online coursework is completed prior to an associate being scheduled for on the floor training. Business Office Manager will monitor training records and staff will not be released for on the floor training until all pre-service topics are complete and certificates are present in their training file. The Executive Director will review new hire training files for completion for the next 60 days and then conduct random audits thereafter as part of ongong quality assurance.  Weekly audits will occur for long term associates and their completion of annual inservice hours.  Executive Director and/or designee to audit training files weekly for 1 month then monthly for 60 days. 4. The Executive Director and Business Office Manager are responsible for this plan of correction.

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: Please refer to:  C 252, C 260, C 262, C 270, C 280, C 302, C 325 and C 340.

Refer to Plan of Correction for C252, C260, C262, C270, C280, C302, C325 and C340

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: Please refer to:  C 270 and C 325

Refer to Plan of Correction for C270 and C325

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 1 sampled resident (# 6) with documented behaviors. Findings include, but are not limited to: Resident 6 was admitted to the memory care community in 01/2022 with diagnoses including Alzheimer's disease and depression. In an interview on 11/15/22, Staff 4 (RN) and Staff 8 (RCC) both stated Resident 6 exhibited negative behaviors, which seemed amplified during "sundowners" times. These reportedly included exit seeking, intrusive wandering, yelling, and "high anxiety symptoms." The resident's current service plan, dated 07/20/22, progress notes, dated 08/15/22 through 11/14/22, temporary service plans, and incident reports were reviewed. The following behaviors were documented:   * "pacing and awake all night"; * "attempting to enter other residents' rooms"; * "yelling and disruptive behavior all day"; * "agitation and exit seeking"; and * "urinating in inappropriate places, such as trash can or floor." There was no documented evidence the facility developed an individualized service plan for management of Resident 6's behavioral symptoms, or provided specific instructions for staff. On 11/18/22 the need to develop individualized behavior plans for residents with behavioral symptoms that negatively impacted the resident or others in the community was discussed with Staff 1 (ED), Staff 2 (District Director of Operations) and Staff 3 (Area Nursing Manager). They acknowledged the findings.

1. Updated service plan has been completed for resident 6 including an individualized behavior plan.  Resident met with Geropsychiatric specialist on 11/22/2022 and specialist's recommendations have been added to resident service plan.   2. Resident records will be reviewed and individualized behavior plans will be added to resident service plans as appropriate. 3. Residents will be evaluated as part of service planning process and interventions for behavioral support will be added as appropriate. Executive Director or designee will conduct random audits of 5 residents weekly to ensure individualized behavior plans are present as needed. 4. The nursing team and Executive Director are responsible for this Plan of Correction.

Based on observation and interview, it was determined the facility failed to ensure residents had access to a secured outdoor space from which they were able to enter and return without staff assistance. Findings include, but are not limited to: The memory care unit was toured on 11/15/22 at 1:25 pm. At that time, the door leading from the unit to the secure outdoor patio was locked and staff needed to unlock it with a key to allow access. A written policy was posted which allowed for the facility to lock the doors for: "abnormal climate, including but not limited to hail, cold, high winds, severe dust storms, extreme high temperatures or combination of any." At the time, there were no severe weather conditions. A CG on the unit stated the door was locked so that residents would not "escape." The door to the patio was observed again to be locked on 11/16/22. A CG stated at that time that the door was locked because it was too cold outside. The unit was toured on 11/16/22 at 11:40 am with Staff 1 (ED). The surveyors reviewed the requirement that residents have access to a secure outdoor area and the posted facility policy. Staff 1 acknowledged the weather conditions did not warrant having the doors locked and that the residents were not being given access to the outdoor area.

1. The door accessing the secure outdoor area is unlocked and is to remain unlocked during daylight hours following the posted policy on inclement weather.   2. Staff will be provided with education on this policy by 12/31/22 to ensure residents have access to the secured outdoor area. 3. Executive Director or designee will check the lock on the door 3 times weekly  for 30 days and weekly for 60 days to ensure staff are following policy. 4. Executive Director is responsible for this plan of correction.

Based on 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 270, C 325, Z 142 and Z 162.

Refer to Plan of Correction for C270, C325, Z142 and Z162

The findings of the re-licensure survey conducted 11/15/22 through 11/18/22 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 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 A situation was identified where there was a failure of the facility to comply with the Departments rules that were likely to cause residents serious harm. An immediate plan of correction was requested in the following areas: OAR 411-054-0027 (1) Resident Rights and Protections; and OAR 411-054-0040 (1-2) Change of Condition and Monitoring. The facility put an immediate plan of correction in place during the survey and the situation was abated.

The findings of the first revisit to the re-licensure survey of 11/18/22 conducted 05/23/22 through 05/25/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Home and Community Based Services Regulations OARs 411 Division 004 and Division 57 for Memory Care Communities. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily 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 re-visit to the re-licensure survey of 11/18/22, conducted 08/02/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation and interview it was confirmed that the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include but not limited to: During an unannounced site visit on 10/04/2022 Compliance Specialist (CS) observed several staff members  to not be wearing their masks appropriately, exposing their nose and mouth while in close proximity to other staff members. CS did not observe any feces covered bedding. These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022. Facility Plan of Correction: In-service staff on masking policies by 10/15/22.

Based on interview and record review it was confirmed that facility failed to provide services to assist the resident with activities of daily living. Findings include but not limited to: In separate interviews during an unannounced site visit on 10/04/2022, Staff #1, Staff #3, Staff #5, Staff #7, Staff #8, and Staff #10 all stated that they are provided weekly shower and laundry schedules and are to sign their initials when those services have been provided. A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff." These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022 Facility Plan of Correction: Facility Management team to pull report and audit call light times 3x/week and discuss in standup meetings to identify patterns and concerns. Trouble shoot as necessary. Will in-service staff on documentation policies related to showers as well as procedures if a shower is missed or resident refuses by 10/15/22. Assigned caregiver to offer shower twice, if resident refuses, CG to notify MT who should offer shower. If refusal continues, MT to notify RCC and resident family/POA.

Based on interview and record review it was confirmed that the facility failed to ensure the implementation of services. Findings include but not limited to: In separate interviews during an unannounced site visit on 10/04/2022, Staff #1, Staff #3, Staff #5, Staff #7, Staff #8, and Staff #10 all stated that they are provided weekly shower and laundry schedules and are to sign their initials when those services have been provided. A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff." These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022 Facility Plan of Correction: Facility Management team to pull report and audit call light times 3x/week and discuss in standup meetings to identify patterns and concerns. Trouble shoot as necessary. Facility will in-service staff on documentation policies related to showers as well as procedures if a shower is missed or resident refuses by 10/15/22. Assigned caregiver (CG) to offer shower twice, if resident refuses, CG to notify Med Tech (MT) who should offer shower. If refusal continues, MT to notify Resident Care Coordinator and resident's family or Power of Attorney.

Based on record review and interview it was confirmed that the facility failed to carry out medication and treatment orders as prescribed. Findings include but not limited to: A review of Resident #7 (R7) after visit summary dated 4/11/2022 and hospital orders dated 4/25/2022 revealed that resident R7 was to receive a medication four times/day for 14 days beginning 4/11/2022. A review of R7's progress notes and  Medication Administration Record (MAR) for April 2022 revealed that resident R7 only received medication twice a day beginning on 4/12/2022. These findings were reviewed with Staff #1 and Staff #11 on 10/04/2022 who were in agreement: Facility Plan of Correction: Education on triple check process to be provided to Med Techs and nurses by 10/15/22.

Based on record review and interview it was confirmed that the facility failed to maintain an accurate medication administration record (MAR). Findings include but not limited to: A review of Resident #7 (R7)'s progress notes revealed that resident went to the hospital on 4/20/2022. A review of R7's MAR revealed inconsistent documentation occurred from 4/20/2022-4/25/2022 when resident was admitted to the hospital, including: medications on hold by physician, absent from home, hold/see nurse notes and hospitalized. These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022 who were in agreement. Facility plan of correction: In service on documentation to be provided to Med Techs and nurses by 10/15/22.

Based on interview and record review it was confirmed that the facility failed to have enough staff to meet the scheduled and unscheduled needs of the residents. Findings include but not limited to: During an unannounced site visit on 10/04/2022, in separate interviews Staff #3 and Resident #4 stated: *Sometimes we do not have enough staff. *Swing shift is a struggle. *If there are not enough people it is hard to get showers done. *Sometimes they have to pull people from the floor to help with meal service. *It can take an hour to get help. A review of facility call light logs for 9/27/2022- 9/29/2022 revealed at least 9 instances of response times over 20 minutes. A review of facility shower and laundry schedules as well as 24 hour communication logs between February 2022 and October 2022 revealed several instances of showers and laundry not being completed and notations of "not having time to do it" and "short staff." These findings were reviewed with and acknowledged by Staff #1 and Staff #11 on 10/04/2022.

Based on record review and interview it was confirmed that facility failed to fully implement an Acuity-Based Staffing Tool (ABST). Findings include but not limited to: A review of the facility's ABST revealed the need for 47.7 hours of care during their day shift. A review of facility staff schedule for October 2022 revealed that the facility has 40 hours of care scheduled. During interview by phone on 10/06/2022, Staff #1 (S1) reported that a Resident Care Coordinator (RCC) comes in for day shift on Sundays and Mondays and works the floor and answers call lights as needed in addition to their normal tasks. They also indicated that day shift starts at 0600. A review of facility's laundry and shower schedule for the week of Sunday 10/02/22 did not include initials or signatures for Staff #8 (S8). A review of S8's time card for 10/3/22 revealed they started work at 0729. The facility was unable to provide any additional documentation that S8 provided care to residents on 10/3/22. These findings were reviewed with and acknowledged by S1 by phone on 10/06/2022.

Based on observation and interview it was confirmed that the facility failed to have staff with sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals. Findings include but not limited to: During an unannounced site visit on 10/04/2022, Compliance Specialist (CS) observed an interaction between Resident #4 (R4), Staff #5 and Staff #6 in which staff had substantial difficulty communicating with resident in English. Compliance Specialist was also unable to interview Staff #5-Staff #7 and required assistance from Staff #3 for translation. These findings were reviewed with Staff #1 and Staff #11 on 10/04/2022 who were in agreement. Facility Plan of Correction: Executive Director to work with HR and regional team to develop a plan for this. Facility Med Techs are able to communicate proficiently in English.