Gresham Pointe Senior Living

OAR 411-054-0025 (7) Facility Administration: Policy & Procedure (7) POLICIES AND PROCEDURES. The facility must develop and implement written policies and procedures that promote high quality services, health and safety for residents, and incorporate the community based care principles of individuality, independence, dignity, privacy, choice, and a homelike environment. The facility must develop and implement: (a) A policy on the possession of firearms and ammunition within the facility. The policy must be disclosed in writing and by one other means of communication commonly used by the resident or potential resident in his or her daily living. (b) A written policy that prohibits sexual relations between any facility employee and a resident who did not have a pre-existing relationship. (c) Effective methods of responding to and resolving resident complaints. (d) All additional requirements for written policies and procedures as established in OAR 411-054-0012 (Requirements for New Construction or Initial Licensure), OAR 411-054-0040 (Change of Condition and Monitoring), OAR 411-054-0045 (Resident Health Services), and OAR 411-054-0085 (Refunds and Financial Management). (e) A policy on smoking. (A) The smoking policy must be in accordance with: (i) The Oregon Indoor Clean Air Act, ORS 433.835 to 433.875; (ii) The rules in OAR chapter 333, division 015; and (iii) Any other applicable state and local laws. (B) The facility may designate itself as non-smoking. (f) A policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner. The policy must include information regarding the collection of medical and forensic evidence that must be obtained within 86 hours of the incident. (g) A policy on facility employees not receiving gifts or money from residents. (h) Protocols for preventing and controlling infection, as described in OAR 411-054-0050. (i) LGBTQIA2S+ Nondiscrimination Notice: “(Name of care facility) does not discriminate and does not permit discrimination, including but not limited to bullying, abuse or harassment, based on an individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status, or based on an individual’s association with another individual on account of the other individual’s actual or perceived sexual orientation, gender identity, gender expression or human immunodeficiency virus status. If you believe you have experienced this kind of discrimination, you may file a complaint with the Oregon Department of Human Services at (provide current contact information).” (j) ABST Policy for accurate and consistent implementation of the ABST. The policy must explain how a facility evaluates and accounts for both scheduled and unscheduled resident needs.

Based on interview and record review, it was determined the facility failed to develop and implement an effective method for responding to and resolving resident complaints. Findings include, but are not limited to: From 03/02/26 to 03/06/26, several sampled and unsampled residents reported grievances to surveyors regarding dining services and slow response times to call lights. On 03/06/26 at 10:33 am, Staff 1 (ED) confirmed she was aware of the resident grievances and reported there was not an established grievance process to respond and resolve complaints. The need to ensure the facility developed and implemented effective methods for responding to and resolving resident complaints was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings.

1. By 4/10/2026, the RDHS/RDO will educate the ED and the HSD on the Sinceri grievance process. The ED and the HSD will then educate all staff on the process by 4/20/2026. All Residents will be educated on how to report concerns through both verbal and written methods to ensure concerns are identified and addressed timely by the ED by 4/20/2026. 2. Concerns identified during Resident Council and Town Hall meetings are documented by the Executive Director using the grievance form and entered into the grievance log for tracking and follow-up. 3. The Executive Director or designee will review the grievance log at least 5 days/week during stand-up to ensure timely response and follow-up. The ED will audit the grievance log weekly x 4 weeks, bi-weekly x 4 weeks and then monthly x 1 month toensure concerns are addressed and resolved. The results of these audits will be reported monthly to the Continuous Quality Improvement committee. 4. ED/Designee

OAR 411-054-0025 (4) Reasonable Precautions (4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare for 1 of 1 sampled resident (# 1) and one unsampled resident who required a modified texture diet and/or fluid consistency. Findings include, but are not limited to: 1. Resident 1 was admitted into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). During the acuity interview on 03/02/26, the resident was identified as having a mechanical soft diet texture and nectar-thick liquids. The resident’s 12/03/25 through 03/02/26 clinical record was reviewed, and the following was identified: * Signed physician orders, dated 03/03/26, identified Resident 1 was on a pureed diet with thickened liquids, effective 01/15/26. * The most recent service plan, dated 01/14/26, indicated Resident 1 required a mechanical soft diet texture, nectar-thick prepackaged liquids, and cut-up food. Not reflective of the physician’s order dated 03/03/26. On 03/04/26 at 12:06 pm, Resident 1 was served lunch that consisted of minced broccoli, mashed potatoes with gravy, and pre-thickened nectar thick apple juice. At 12:09 pm the resident was served apple cake. At 12:10 pm the apple cake was removed and replaced toward the end of the meal with chocolate ice cream (which is considered a thin liquid). During an approximate five-minute period at 12:49 pm, the resident was observed coughing intermittently, his/her tablemates alerted staff “[s/he] was choking” and a caregiver checked on him/her. During an interview at 1:05 pm on 03/04/26, Staff 5 (Culinary Services Director) acknowledged the meal provided at lunch was “minced and moist” and she had never been aware of Resident 1 requiring a pureed diet in the year she had been working at the facility. On 03/04/26 at 3:30 pm, Staff 1 (ED) provided a discontinue order for the pureed diet, signed 03/04/26 with an effective discontinue date of 01/15/26, and indicated Resident 1 was “never supposed to be on a pureed diet” per hospice, despite hospice orders indicating a pureed diet signed on 03/03/26. On 03/04/26 at 4:20 pm, Staff 2 (Director of Nursing/LPN) indicated Resident 1 should be on a minced and moist diet texture and nectar-thick liquids and provided hospice admission orders, dated 12/23/25, that confirmed the modified diet and fluid consistency. On 03/04/26 at 4:25 pm Resident 1 was served for dinner thin pureed beef stew and regular thin coffee. Not following the current order diet order dated, 12/23/25, of minced and moist diet texture and nectar-thick liquids. During an interview on 03/04/26 at 4:30 pm, Staff 22 (Dining Staff/Cook) acknowledged he prepared dinner for Resident 1 and indicated he was told Resident 1 required a mechanical soft diet and instructions were “to blend it up.” Staff 23 (Resident Assistant) confirmed the resident was served regular coffee, not nectar thick. At 4:40 pm the surveyor shared findings with Staff 2 and requested the stew and coffee be removed, as it was not the resident’s ordered diet consistency. On 03/04/26 at 4:48 pm the resident was observed eating cut up hot dogs, macaroni salad, a slice of bread and pre-thickened nectar-thick water. The hot dogs, macaroni salad and bread were not minced, and the bread was not softened and moist as required for a minced and moist diet texture. At 4:49 pm the survey team requested the meal be replaced with one reflective of the resident’s ordered diet texture, and observations confirmed the resident received the correct diet texture. On 03/05/26 at 12:50 pm, Staff 1 (ED) acknowledged the facility had not followed the proper diet texture and fluid consistency for Resident 1 and instructed Staff 2 (Director of Nursing/LPN) to provide training for all of the cooks responsible for preparing food and only having pre-thickened fluid available. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including ensuring residents received the appropriate therapeutic diet texture, was discussed with Staff 1 and Staff 2 on 03/06/26 at 12:15 pm. They acknowledged the findings. 2. During the acuity interview on 03/02/26, an unsampled resident was identified as requiring a mechanical soft diet texture, which is a fork-mashable consistency. A physician’s order, noted 02/19/26, confirmed a diet texture of “Soft and Bite-Sized (aka [otherwise known as] Mechanical Soft, Level 3)”. On 03/05/26 during an observation, the survey team requested the lunch that was prepared for the unsampled resident, which consisted of a chopped-up vegetarian burger that contained corn and was not fork-mashable. On 03/05/26 at 12:25 pm, Staff 5 (Culinary Services Director) confirmed corn was not considered mechanical soft and provided the resident with an alternative meal that was reflective of the resident’s ordered diet texture. On 03/05/26 at 12:50 pm, Staff 1 (ED) acknowledged the facility had not followed the proper diet texture and fluid consistency for the unsampled resident. She had instructed Staff 2 (Director of Nursing/LPN) to provide training for all of the cooks responsible for preparing food. The need to ensure the facility exercised reasonable precautions against any condition that could threaten the health, safety, or welfare of residents, including ensuring residents received the appropriate therapeutic diet texture and fluid consistency, was discussed with Staff 1 and Staff 2 on 03/06/26 at 12:15 pm. They acknowledged the findings.

1. Resident #1 diet order was clarified and updated on 3/7/2026 by the HSD. Diet orders were verified and communicated to staff to ensure appropriate food and fluid consistency is provided. On 3/5/2026, Culinary Staff received education on the requirement to follow prescribed diet orders, including texture-modified diets and fluid consistencies, to ensure resident safety. 2. The ED and the HSD will be educated on the correct diet process and notification to all staff, including culinary staff. Diet orders will be reviewed during service planning, with any change in condition, and as needed to ensure accuracy by the HSD or designee. The HSD/ED will update the diet roster and provide a current and up to date copy to the kitchen at least monthly or with any changes. 3. The ED/HSD/Designee will audit at least 4 meals a week x 4 weeks, 3 meals a week x 4 weeks, and then randomly for correct diet service. 4. The HSD or designee is responsible for oversight of the process.

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 were available to staff, reflective of the resident’s care needs, provided clear direction regarding the delivery of services, and were implemented for 4 of 4 sampled residents (#’s 1, 2, 4 and 5), whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath. The resident’s 01/27/26 service plan and 12/02/25 through 03/02/26 temporary service plans (TSP’s) were reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. The following was identified: The service plan was not reflective of the resident’s care needs, lacked clear direction to staff and was not implemented in the following areas: * Assistance with oxygen concentrator, including the need to fill the humidifier bottle with distilled water PRN and clean the air filter weekly; * Use of bedside commode including assistance with emptying the commode and cleaning it PRN; and * The need to anticipate the resident’s needs by offering assistance before and after meals with toileting, transfers and nighttime cares and to ensure s/he had personal items within reach was documented in a TSP dated 01/07/26; however the information was not included in the 01/27/26 service plan. On 03/06/26 at 11:45 am, Staff 1 (ED) acknowledged the information included on the 01/07/26 TSP was still pertinent, however was not transferred to the 01/27/26 service plan. The need to ensure service plans were reflective of the resident’s care needs, provided clear direction regarding the delivery of services, and were implemented was discussed with Staff 1 on 03/06/26 at 11:45 am. She acknowledged the findings. 2. Resident 2 moved into the facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s clinical record, including the 03/01/26 service plan, was reviewed, interviews with staff and the resident were conducted, and observations were made. The service plan was not reflective of the resident’s current care needs, lacked clear direction regarding the delivery of services, or was not implemented in the following areas: * Current status, including independence with toileting, transferring, repositioning, oral hygiene, grooming, and personal hygiene and will call for assistance as needed; * Hospice information including use of assistive devices and services provided; * Daily weights; * Oxygen assistance including cleaning, maintenance, and safety instruction; * Edema management instruction including interventions and what and when to report to the RN and/or hospice provider; * Assistive devices used for toileting, including use of a raised toilet seat and commodes, and instruction related to cleaning and safety; * Maintenance of assistive devices to ensure devices were safe and in working condition related to the resident’s four wheeled walker and commodes; * Assistive devices used for hearing including use of a pocket sound amplifier with headphones, and instruction related to use, cleaning, and charging; * Self-administration of medication information and instructions; * Sleep schedule and use of recliner at times to sleep; * Dining needs and preferences including desire for finger foods and instructions related to when meals were delivered to the resident’s room; * Emergency evacuation assistance, including number of staff needed; and * Assistance with room temperature, including the use of a fan and instruction related to when to open/close the window beside the resident’s recliner. On 03/02/26 at 1:45 pm, Resident 2 was observed to use continuous oxygen, to transfer independently out of his/her recliner and ambulate to the kitchen. The resident reported the need to be escorted long distances in his/her wheelchair and needed assistance with the oxygen tubing at times. On 03/06/26 at 9:26 am, Staff 15 (Resident Assistant) reported to assist the resident with dressing/undressing, setting up meals, and responding to the call light when the resident used his/her pendant for stand-by assistance. The need to ensure service plans were reflective of residents’ needs and preferences, provided clear direction regarding the delivery of services, and were implemented, was reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings. 3. Resident 1 moved into the facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident’s clinical record was reviewed, observations were made, and interviews were conducted. The following was identified: a. During the acuity interview on 03/02/26, facility staff reported service plans were stored in the service plan binder located in the Neighborhood Room for direct care staff to review. Upon observation of the binder at 11:53 am on 03/02/26, the service plan for Resident 1 was dated 12/08/25. An updated service plan following a significant change of condition, dated 01/14/26, was provided by the facility at 11:15 am on 03/05/26, but this was not available to staff at the time of survey entrance. b. The 12/08/25 service plan was not reflective of the resident’s current care needs, lacked clear instructions and was not implemented in the following areas: * Aspiration precautions including distant supervision “within arm's reach”, remain upright at 90 degrees for 60 minutes following food or beverage intake, mechanical soft diet texture and nectar thickened fluids, and oral care at least twice a day; * Fall precautions including leaving call pendant within reach, hazards removed from the walkway in room, and instructions regarding placement of wheelchair for accessibility; * How the resident exhibited agitation and non-pharmaceutical interventions; * Incontinent of bowel; * Cognition, including poor short-term memory and impulsivity; and * Preferences for keeping door open and location for toileting assistance. The resident’s service plan indicated the resident was continent of his/her bowels, and instructed staff to keep items within reach including the call light and his/her assistive device in resident’s sight for a visual reminder. The service plan lacked information on the resident’s cognition. The resident was taking a PRN psychotropic medication for anxiety and restlessness, but the non-pharmaceutical interventions were not on the service plan for staff to try prior to administering the medication. During interviews with the resident, it was noted s/he preferred to have toileting assistance in front of the recliner chair and indicated the door was left open for staff convenience, but s/he preferred to be asked whether to keep the door open or closed. Observations during the survey revealed the following: * The resident’s door remained open the majority of the time. Staff were not observed to ask the resident if s/he preferred the door to be closed when they left the residents room; * Staff provided toileting assist in front of the recliner and in the bathroom; * The resident was served the incorrect diet texture and fluid consistency during lunch and dinner service on 03/04/26, was assisted into a reclined position less than 30 minutes after finishing lunch and a white substance was observed between his/her teeth after breakfast on two occasions; and * On 03/05/26, when staff left the room a ceramic dog, approximately 9-inches tall, was left in the resident’s pathway creating a trip hazard, the call pendant was not within reach, and the wheelchair was not in sight or accessible. Interviews with care staff during the survey noted the resident was incontinent of his/her bowel and was forgetful. Staff were unaware the resident had a PRN medication for agitation or restlessness and what non-pharmaceutical interventions could be provided for when s/he displayed the behavior. The need to ensure residents’ current service plans were readily available to staff, were reflective of the resident’s status and care needs, provided clear instructions to staff regarding the delivery of services, and was implemented was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 4. Resident 5 moved into the facility in 10/2023 with diagnoses including diabetes and hypertension. The resident’s 01/13/26 service plan and 12/01/25 through 03/02/26 temporary service plans were reviewed. Observations and interviews with staff and the resident were conducted. The service plan was not reflective of resident care needs and lacked clear direction to staff in the following areas: a. The service plan indicated the resident was independent with dressing, bathing, and toileting. However, interview(s) with staff and the resident during the survey on 03/02/26 through 03/06/26 indicated resident required one staff assistance with above care. b. Resident 5 had a suprapubic catheter and required staff assistance to empty and to change to/from an overnight bag to a leg bag in the morning and at bedtime. The service plan lacked clear directions to staff on providing catheter care. The need to ensure service plans were reflective of resident care needs and provided clear direction to staff was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31am. They acknowledged findings.

1. Residents 1, 2, 4, and 5 service plans will be updated to be reflective of care by the HSD by 4/10/2026. 2. An audit of all current resident service plans will be completed by 4/15/2026 by the HSD or designee. Any service plan that does not provide clear instruction for staff to follow will be updated by the HSD/ED/Designee by 4/30/2026. 3. Service plans will be reviewed and updated at least every 90 days and as needed with any change of condition to ensure they reflect current resident needs and provide clear direction for care. Temporary service plans will be reviewed at least 4 days/week in the clinical huddle meeting and as needed to ensure information is incorporated into the permanent service plan. Service plans will be printed and placed in a binder for staff to view/read/access. 4. The HSD/ED/Designee are responsible for ensuring this happens

OAR 411-054-0036 (5) Service Plan: Service Planning Team (5) SERVICE PLANNING TEAM. The service plan must be developed by a Service Planning Team that consists of the resident, the resident's legal representative, if applicable, any person of the resident's choice, the facility administrator or designee and at least one other staff person who is familiar with, or who is going to provide services to the resident. Involved family members and case managers must be notified in advance of the service-planning meeting.(a) As applicable, the Service Planning Team must also include:(A) Local APD or AAA case managers and family invited by the resident, as available.(B) A licensed nurse if the resident shall need, or is receiving nursing services or experiences a significant change of condition as required in 411-054-0045(1)(f)(D) (Resident Health Services).(C) The resident's physician or other health practitioner.(b) Each resident must actively participate in the development of the service plan to the extent of the resident's ability and willingness to do so. If resident participation is not possible, documentation must reflect the facility's attempts to determine the resident's preferences.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a service planning team that included the resident, the resident's legal representative if applicable, any person of the resident’s choice, the administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 4 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath and pain. The resident’s most recent service plan, dated 01/27/26, lacked evidence that the resident participated in the development of the service plan. In an interview with Resident 4 on 03/04/26 at 9:45 am, the resident stated s/he had not participated in the development of the 01/27/26 service plan and was not aware of the details noted in the service plan. The need to ensure Resident 4 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings. 2. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements) and had a history of difficulty swallowing. The resident’s most recent service plan, dated 01/14/26, lacked evidence that the resident, or the resident’s legal representative, participated in the development of the service plan. During an interview on 03/06/26 at 10:35 am with Staff 1 (ED), she confirmed she had not started meeting with residents and their families to discuss the service plans in the last 90 days “with the new system”. The need to ensure Resident 1 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 12:30 pm. She acknowledged the findings. 3. Resident 6 was admitted to the facility in 11/2024 with diagnoses including epilepsy and dementia. The resident’s most recent service plan, dated 01/03/26, lacked evidence that the resident, or the resident’s legal representative, participated in the development of the service plan. During an interview at 12:25 pm on 03/04/26, the surveyor was approached by Resident 6 and Witness 2 (Family). Witness 2 shared concerns of multiple attempts since January of attempting to get a copy of Resident 6’s service plan and denied having had a service plan meeting in the last year. The need to ensure Resident 6 participated in the development of his/her service plan was discussed with Staff 1 (ED) on 03/06/26 at 12:30 pm. She acknowledged the findings. 4. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s most recent service plan, dated 03/01/26, lacked evidence the resident participated in the development of the service plan. On 03/02/26 at 1:45 pm, the resident reported s/he had not participated in the development of the service plan. The need to ensure service plans were developed by a Service Planning Team that included the resident was reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings.

1. Residents 1, 2, 4, and 6 were offered a care conference by the HSD on 3/5/2026. 2. By 4/10/2026, the Regional Director of Health Services (RDHS) will educate the Executive Director (ED) and the Health Services Director (HSD) on the notification, documentation and involvement of residents and/or their representatives in the service planning process. 3. Scheduled care conferences will be discussed at daily stand up at least 4 days/week. Care conferences will be held at a minimum of: at move-in, quarterly, and with any change of condition service plan updates. Evaluations/service plans due and care conferences scheduled with be reviewed at least 5 days per week in daily stand-up. The ED and/or designee will audit care conference schedules weekly x 4 weeks, bi-weekly x 4 weeks, and then monthly to review participation and documentation. The results of these audits will be reported to the monthly Continuous Quality Improvement Committee. 4. ED/HSD/Designee

OAR 411-054-0040 (1-2) Change of Condition and Monitoring (1) CHANGE OF CONDITION. These rules define a resident's change of condition as either short term or significant with the following meanings: (a) Short term change of condition means a change in the resident's health or functioning that is expected to resolve or be reversed with minimal intervention or is an established, predictable, cyclical pattern associated with a previously diagnosed condition. (b) Significant change of condition means a major deviation from the most recent evaluation that may affect multiple areas of functioning or health that is not expected to be short term and imposes significant risk to the resident.(c) If a resident experiences a significant change of condition that is a major deviation in the resident's health or functional abilities, the facility must evaluate the resident, refer to the facility nurse, document the change, and update the service plan as needed. (d) If a resident experiences a short-term change of condition that is expected to resolve or reverse with minimal intervention, the facility must determine and document what action or intervention is needed for the resident. (A) The determined action or intervention must be communicated to staff on each shift. (B) The documentation of staff instructions or interventions must be resident specific and made part of the resident record with weekly progress noted until the condition resolves. (2) MONITORING. The facility must have written policies to ensure a resident monitoring and reporting system is implemented 24-hours a day. The policies must specify staff responsibilities and identify criteria for notifying the administrator, registered nurse, or healthcare provider. The facility must: (a) Monitor each resident consistent with his or her evaluated needs and service plan; (b) Train staff to identify changes in the resident's physical, emotional and mental functioning and document and report on the resident's changes of condition; (c) Have a reporting protocol with access to a designated staff person, 24-hours a day, seven days a week, who can determine if a change in the resident's condition requires further action; and (d) Provide written communication of a resident's change of condition, and any required interventions, for caregivers on each shift.

Based on interview and record review, it was determined the facility failed to determine and document actions or interventions for changes of condition, monitor and note progress of the conditions, at least weekly, to resolution, and monitor residents consistent with his or her evaluated needs and service plan for 3 of 4 sampled residents (#s 1, 2, and 5) who had documented changes of condition, including multiple falls. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). Resident 1's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/02/25 through 03/02/26 revealed the following: * Fall interventions identified on the 12/08/25 service plan available to staff indicated reminders to use the wheelchair, keep the device in sight, within reach and locked, safety rounding, wear supportive footwear, keep personal possessions and call light within reach, remove hazards from room and walkway, provide meal escort, stand-by assist for transfers, safety checks and a toileting schedule. Observations of the resident during the survey revealed Resident 1 received wheelchair escorts to meals, staff provided assistance with transfers and toileting, the call pendant and wheelchair were not consistently placed within sight and reach, s/he wore supportive footwear, and staff provided safety checks. * On 12/02/25 Resident 1 had a non-injury fall with interventions noted on the incident report to keep the assistive device in sight as a visual reminder. There was no documented evidence the determined intervention was communicated to staff on each shift, and implemented. * On 12/06/25 Resident 1 had a non-injury fall after sliding from the chair. Interventions identified from the incident report included “Increase observation of resident during waking hours.” There was no documented evidence the facility communicated the new intervention to staff, was implemented and monitored for effectiveness. * On 12/10/25 Resident 1 attempted to self-transfer and had a non-injury fall. Interventions identified from the incident report included escort to meals and “Increase observation of resident during waking hours.” Although providing meal escorts was on the service plan, there was no documented evidence “increase observation of resident during waking hours” was communicated to staff on all shifts, and no documented evidence either intervention were implemented or reviewed for effectiveness. * On 12/25/25 Resident 1 had a non-injury fall after falling out of his/her chair. Interventions identified from the incident report included the same interventions from the 12/10/25 fall and no documented evidence the interventions were communicated to staff on all shifts, implemented or reviewed for effectiveness. There was no documented evidence the facility consistently communicated fall interventions to staff on all shifts, monitored the interventions for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. On 03/06/26 at 12:15 pm, Staff 1 (ED) confirmed the interventions following multiple falls were not communicated to staff on all shifts and monitored for implementation and effectiveness. The need to ensure the facility communicated identified interventions to staff on all shifts, and monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 2. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension Resident 5's clinical record, service plan, temporary service plans, incident reports, and observation notes reviewed from 12/02/25 through 03/02/26, revealed the following: Fall interventions identified on the 01/13/26 service plan available to staff indicated safety checks for increased fall risks. Report to Health Services Director (HSD) and/or designee any observed or reported falls, change in gait/balance, change in toileting ability, and any observed safety hazards in Resident 5’s environment (cluttered walkways, poor lighting, adaptive equipment needing repair). Observation of resident during the survey revealed Resident 5 was utilizing a walker for ambulation, wearing slippers, had call pendant on over neck, and was able to call staff for assistance as needed. *On 12/30/25 Resident 5, had a non-injury fall from rolling out of bed and bumping back of his/her head. Interventions identified on incident report included “increase observation during waking hours”. However, there was no documented evidence the determined intervention was communicated to staff on each shift and implemented. * On 01/24/26 Resident 5 had a non-injury fall while ambulating his/her walker. Intervention identified on incident report included “to keep assistive device in sight”. However, there was no documented evidence the facility reviewed interventions from previous fall, communicated the new intervention to staff, implemented and monitored for effectiveness. * On 02/16/26 Resident 5 had a non-injury fall due to power being out, resident stated was attempting to go find out what happened to the power and slipped. Intervention identified on incident report investigation included to ensure proper footwear and night lights. However, there was no documented evidence the facility reviewed interventions from previous fall, communicated the new intervention to staff, implemented and monitored for effectiveness. Observation of resident’s room on 03/06/26, there were no night lights in the bedroom, living room or bathroom. Interview with the resident conducted on 03/06/26, stated s/he was not aware of night lights in his/her unit. There was no documented evidence the facility consistently communicated fall interventions to staff on all shifts, monitored the interventions for implementation and effectiveness consistent with the resident’s evaluated needs and service plan. On 03/06/26 at 09:31 am, Staff 1 (ED) confirmed the interventions following multiple falls were not communicated to staff on all shifts and monitored for implementation and effectiveness. The need to ensure the facility communicated identified interventions to staff on all shifts, and monitored fall interventions consistent with evaluated needs and service plan was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 9:31 am on 03/06/26. They acknowledged the findings. 3. Resident 2 moved into the facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s 02/02/26 through 03/06/26 clinical record was reviewed, interviews with the resident and staff were conducted, and observations of the resident were made. Resident 2 was identified to have the following changes of condition: a. On 02/05/26 the resident returned from the emergency department to the facility with diagnoses including shortness of breath and hyponatremia (low sodium). An RN assessment was completed on 02/06/26 with documented interventions; however, there was no documented evidence the determined interventions were documented and communicated to staff on each shift, and were implemented. b. Resident 2 had a diagnosis of lower leg edema and on 02/10/26 the facility RN implemented instruction to notify the nurse of a three-pound gain or loss from the previous weight. Additional interventions were to monitor respiratory status, edema, and fluid balance. However, there was no documented evidence the nurse was notified of a three-pound weight gain or loss or documentation the additional interventions were implemented or communicated to staff on each shift. c. On 02/19/26 the resident was sent to the emergency department for shortness of breath and increased lower leg edema. A RN assessment was completed on 02/20/26 with documented interventions, however, there was no documented evidence the determined interventions were documented and communicated to staff on each shift, and were implemented. d. On 02/24/26, a weekly follow-up RN assessment was completed with documented interventions, however, there was no documented evidence the determined interventions were documented on and communicated to staff on each shift, and were implemented. On 03/04/26 at 10:35 am, the above was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) and no other documentation was provided. The need to ensure the facility communicated the determined action or interventions to staff on each shift for changes of condition was reviewed with Staff 1 on 03/06/256 at 11:30 am. She acknowledged the findings.

1.Residents # 1, 2, and 5 will be updated by the HSD by 4/10/26 to ensure appropriate interventions were included on the service plan. 2. The RDHS will educate the ED and the HSD by 4/10/2026 on the change of condition process and requirements for monitoring. The ED and HSD will educate all staff on reviewing/signing of temporary service plans in the binder at the start of their shifts by 4/20/2026. 3. Temporary service plans and documentation will be reviewed at least 4 times/week during clinical huddle and as needed to ensure they reflect current interventions and to determine if ongoing needs should be incorporated into the permanent service plan. Information from temporary service plans will be transferred to the permanent service plan when appropriate, by the HSD or designee . 4. HSD/ED/Designee

OAR 411-054-0050(1-5) Infection Prevention & Control (Amended 03/18/2022)(1) Facilities must establish and maintain infection prevention and control protocols to provide a safe, sanitary and comfortable environment. This includes protocols to prevent the development and transmission of communicable diseases.(2) Each facility must designate an individual to be the facility ' s "Infection Control Specialist" responsible for carrying out the infection prevention and control protocols and serving as the primary point of contact for the Department regarding disease outbreaks. The Infection Control Specialist must:(a) Be qualified by education, training and experience or certification; and(b) Complete specialized training in infection prevention and control protocols within three months of being designated under this paragraph, unless the designee has received the specialized training within the 24-month period prior to the time of the designation. The Department will describe trainings that will be acceptable to meet the specialized training requirement in rule, by January 1, 2022.(3) Each facility must establish infection prevention and control protocols and have an Infection Control Specialist, trained as required in this rule, by July 1, 2022.(4) Facilities must comply with masking requirements as prescribed in OAR 333-019-1011 or, if applicable, OAR 437-001-0744, to control the spread of COVID-19.(5) Facilities must comply with vaccination requirements for COVID-19 as prescribed in OAR 333-019-1010.Stat. Auth.: ORS 410.070, 443.004, 443.012, 443.450Stats. Implemented: ORS 443.004, 443.400-443.455, 443.991

Based on observation and interview, it was determined the facility failed to follow established infection prevention and control protocols to ensure a safe, sanitary, and comfortable environment for 2 of 2 sampled residents (#s 1 and 5) whose ADL care was observed. Findings include, but are not limited to: 1. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident was identified in the acuity interview as requiring assistance for toileting. a. On 03/03/25 at 10:46 am, the surveyor observed one staff provide incontinence care for Resident 1 by the table in front of his/her recliner. Resident 1 stood up from the recliner and held onto the table for support. Staff placed a trash bag on the floor, donned gloves, set aside a clean brief and began assisting the resident remove his/her pants and brief. The caregiver removed the soiled brief, placed it in the trash bag and used wipes to clean the resident’s peri-area following a bowel movement. Once clean, the resident sat down on the recliner chair and with the same dirty gloves the caregiver touched the resident’s slippers, pants, clean brief, a clean chucks pad, the controller for the recliner, and the wheelchair. b. On 03/04/25 at 12:55 pm, the surveyor observed one staff assist the resident with incontinence care in his/her bathroom. The staff donned gloves and after the resident stood up using the grab bar, the caregiver removed his/her soiled briefs and pants and assisted the resident onto the toilet. With the same soiled gloves, the caregiver touched the resident’s clean clothes in the laundry basket and brought a clean pair of pants, a brief and wipes into the bathroom. She removed the soiled pants and set them on the bathroom floor, used wipes to clean the peri-area following a bowel movement, and with the same dirty gloves touched the clean pants, briefs, wheelchair handles and brakes, a pillow, jacket, a clean chucks pad, blanket, and the controller for the recliner. The need to ensure infection prevention and control protocols were followed was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 10/2023 with diagnoses including diabetes and hypertension. On 03/04/26 at 1:10 pm, during observations, Staff 21 (Resident Assistant) donned gloves and did not perform hand hygiene prior. Staff 21 picked up a used urinal and stated she needed to wait for a MT to bring cleaning supplies to perform the resident’s catheter care. After touching the used urinal, Staff 21 touched her radio located in her pocket, without performing hand hygiene. Staff 21 stated will proceed to empty catheter then return to clean the catheter opening later. Placed the urinal on the bare carpet without a protective barrier and proceeded to empty the resident’s catheter bag. Staff 21 emptied the urinal into the toilet, rinsed the urinal in the sink and was not observed to complete hand hygiene after doffing gloves. The need to maintain effective infection prevention and control protocols was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31am. They acknowledged the findings.

1. On 3/26/2026, the HSD educated all Staff on infection control practices, including proper hand hygiene, appropriate glove use, and the separation of clean and dirty tasks during resident care. Education included when to perform hand hygiene, when to change gloves, and proper handling of contaminated items and equipment to prevent cross-contamination. 2. The HSD/Designee will perform an infection control audit of at least 10% staff weekly x 4 weeks, to include watching handwashing and incontinence care, and identify any deficient practices and provide education as needed. The results of these audits will be reported monthly to the Continuous Quality Improvement Committee. 3. The ED/HSD will perform spot audits on Infection control practices during resident care on an ongoing basis to ensure staff are following proper hand hygiene, glove use, and clean versus dirty task practices. 4. The Executive Director or designee is responsible for oversight of the process.

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 interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legal prescriber and for which the facility was responsible to administer and provided resident-specific parameters and instructions for PRN medications for 4 of 4 sampled residents (#s 1, 2, 4, and 5) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension. The resident’s 02/01/26 through 03/02/26 MAR and current physician’s orders were reviewed. The following was identified: The resident’s MAR lacked a reason for use for the following medications: * Finasteride 5mg tablet; and * Haloperidol 1mg tablet. The need to ensure the MAR included the reason for use for all medications was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31 am. They acknowledged the findings. No further documentation was provided. 2. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s clinical record was reviewed, including the 02/01/26 through 03/02/26 MAR, and physician’s orders. The following was identified: a. The MAR lacked a reason for use for the following orders: * Polyvinyl alcohol 1.4%; * Trelegy ellipta; * Continuous oxygen; * Furosemide 20 mg; * Albuterol inhaler; * Bisacodyl 5 mg; and * Diclofenac sodium 1%. b. The MAR indicated a range for administration for the following orders: * Diclofenac sodium 1% gel; and * Albuterol inhalation aerosol inhaler. c. The resident had the following PRN bowel medications that lacked clear instruction to staff for the order of administration: * Polyethylene glycol powder – three times daily as needed for “no [bowel movement] in [two] days”; * Bisacodyl suppository – daily as needed; * Bisacodyl tablet – daily as needed; and * Senna/Docusate tablet – daily as needed. On 03/04/26 at 9:18 am, Staff 11 (Medication Assistant) reported the PRN bowel medication instruction for the order of administration was unclear for this resident. The need to ensure MARs included the reason for use and dose for each medication and provided clear instruction for the order of administration when multiple PRN medications were used, was reviewed with reviewed with Staff 1 (ED) on 03/06/26 at 11:30 am. She acknowledged the findings. 3. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). The resident’s 02/01/26 through 03/02/26 MAR and physician’s orders were reviewed. The following was identified: The MAR lacked a reason for use for the following orders:: * Carvedilol 6.25 mg; * Citalopram 10mg; * Haloperidol 0.5mg; and * Nitrofurantoin macro 100mg. The need to ensure the MAR included the reason for use for all medications was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 12:15 pm. They acknowledged the findings. 4. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including asthma, hypothyroidism and pain. The resident’s physician’s orders and 01/01/26 through 01/26/26 MARs were reviewed. The following was noted: a. The following medications had no reason for use: * Eliquis 2.5 mg; * Fluticasone; * Isosorbide 30 mg; * Levothyroxine 12.5 mcg; * Montelukast 10 mg; * Omeprazole 40 mg; * Pregabalin 75 mg; * Spironolactone 50 mg; * Guaifen 400 mg; and * Ondansetron 4 mg. b. The MAR lacked parameters regarding the sequential order for use for the following PRN medications prescribed for the same diagnosis: * Morphine sulfate 20 mg/ml solution and acetaminophen 500 mg (for pain); and * Hydroxyzine 20 mg and Benadryl itch cream (for itchiness). The need to ensure the medication record contained a reason for use and the sequential order for use of PRN medications prescribed for the same diagnosis was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1The HSD/RN reviewed the MARS for residents # 1, 2, 4, and 5 on 3/9/2026, and updated them to ensure there were resident specific parameters on the PRN medication orders. 2. On 4/1/2026, the RDHS will educate the HSD and the ED regarding appropriate medication parameters, clear direction for administration and sequencing if multiple PRNs are noted for the same diagnosis. The HSD has reviewed All current medication administration records to ensure medications include a documented reason for use and appropriate instructions for administration. Identified medications lacking sufficient direction, including PRN medications without clear parameters or sequencing, were clarified with the prescribing provider and updated to reflect complete and accurate information. 3. Medication orders will be reviewed during the third check by the HSD/ED to ensure they have all of these items. 4. The HSD/ED are responsible. .

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 observation, interview, and record review, it was determined the facility failed to ensure residents who chose to self-administer their medications were evaluated and had 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 2 and 4) who were reviewed for self-administration of medications. Findings include, but are not limited to: 1. Resident 2 moved into the assisted living facility in 02/2026 with diagnoses including chronic diastolic heart failure with exacerbation, chronic respiratory failure with hypoxia, and stage IV chronic obstructive pulmonary disease. The resident’s 02/02/26 through 03/06/26 clinical record, including current signed physician orders, dated 02/26/26, were reviewed, observations of the resident were made, and interviews with the resident and staff were conducted. The following was identified: On 03/04/26 at 2:07 pm, the resident reported to self-administer an albuterol inhaler, as needed. The medication was observed in the resident’s apartment during the interview. On 03/06/26 at 9:54 am, Staff 11 (Medication Assistant) reported the resident kept a PRN albuterol inhaler in his/her apartment to self-administer as needed. There was no documented evidence of a physician or other legally recognized prescriber’s written order for the resident to self-administer a PRN albuterol inhaler. On 03/04/26 at 8:24 am, the resident’s self-administration evaluation was requested from Staff 1 (ED) and Staff 2 (Director of Nursing/LPN). At 11:27 am, Staff 1 confirmed there was no documented evidence of a self-administration evaluation. The need to ensure residents who chose to self-administer their medications were evaluated and had a physician's or other legally recognized practitioner's written order of approval for self-administration of prescription medication, was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings. 2. Resident 4 moved into the assisted living facility in 09/2025 with diagnoses including shortness of breath Review of Resident 4’s physician’s orders and MAR dated 02/01/26 through 03/02/26, and progress notes dated 12/02/25 through 03/02/26 revealed the resident was prescribed albuterol inhaler PRN for shortness of breath. During an interview on 03/03/26 at 9:30 am, Resident 4 stated s/he self-administered the albuterol inhaler. The medication was observed in the resident’s apartment during the interview. An order for the prescription medication to be self-administered and the resident's quarterly self-administration evaluation was requested on the same day at 11:15 am and on 03/04/26 at 9:35 am. The facility was unable to provide the requested physician's order prior to survey exit. The need to ensure residents who chose to self-administer medications were evaluated for safety and had a physician's written order of approval for the self-administration of prescription medications was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1.The HSD completed a self medication evaluation on Residents #2 and 4 on 3/5/2026. 2. The RDHS will educate the HSD and the ED on the policy for self medication evaluations by 4/10/2026. The HSD will audit and complete any out of date self-medication evaluations by 4/15/2026 and obtain any missing physician orders, if resident continues to be safe to self administer medications. Self medication evaluations will be completed by the HSD per policy monthly. 3. The ED/HSD will audit monthly self medication evaluations and report the results of the audit to the Continuous Quality Improvement Committee. 4. HSD/ED.

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 document non-pharmacological interventions were attempted with ineffective results prior to administering PRN psychotropic medications and/or ensure staff administering medications knew the common side effects of the medications and when to contact a health professional regarding side effects for 2 of 3 sampled residents (#s 1 and 5) who had documented administrations of PRN psychotropics. Findings include, but are not limited to: 1. Resident 5 moved into the assisted living facility in 10/2023 with diagnoses including diabetes and hypertension. Review of Resident 5’s current physician orders and MAR, dated 02/01/26 through 03/02/26, revealed the resident was prescribed the following PRN psychotropic medication: * Haloperidol 0.5mg every four hours as needed for agitation. The MAR revealed administration of PRN haloperidol on 02/04/26. There was no documented evidence that non-pharmacological interventions were attempted with ineffective results prior to administering the psychotropic. In an interview on 03/04/26 at 11:40 am, Staff 8 (RCC) and Staff 10 (Medication Assistant) reviewed the electronic record and observation notes of the PRN psychotropic administration for Resident 5. Staff 8 and Staff 10 confirmed the lack of documentation of non-drug interventions attempted. The need to document non-pharmacological interventions attempted without effective results prior to administration of a PRN psychotropic medication of a PRN psychotropic medication was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) on 03/06/26 at 9:31 am. They acknowledged the findings. 2. Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). A review of Resident 1’s current physician orders and MAR, dated 02/01/26 through 03/02/26 and progress notes identified the following: Resident 1 had a signed physician order for haloperidol 1 mg, 0.5 tablet two times daily as needed for restlessness and agitation. There were no non-pharmacological interventions documented in the resident's chart as having been attempted and ineffective prior to the PRN haloperidol being administered once on 02/14/26 and 02/15/26, and the MAR lacked common side effects of the medication and instructions for when to contact a health professional regarding side effects. During an interview on 03/04/26 at 2:44 pm, Staff 16 (Medication Assistant) confirmed the MAR did not indicate the side effects of the PRN haloperidol and when to contact a health care professional. She believed documentation regarding non-pharmacological interventions were attempted and found ineffective prior to use would be completed in the observation notes but was not sure since she had not administered this medication to Resident 1. Observation notes from 02/14/26 and 02/15/26 noted the PRN medication was given but lacked documented evidence non-pharmacological interventions were attempted and found ineffective prior to the medication being administered. The need to document non-pharmacological interventions attempted and ineffective prior to administration of a PRN psychotropic and to ensure all staff administering the medication knew common side effects and when to contact a health professional regarding side effects was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. The HSD/RN updated residents #1 and 5 MAR on 3/5/26 with non-pharmacological interventions. 2. The HSD reviewed all PRN psychotropic medications orders to ensure non-pharmacological interventions and potential side effects are identified and documented on the MAR. The ED/HSD educated Staff on the requirement to attempt and document at least 3 non-pharmacological interventions prior to administering PRN psychotropic medications on 3/5/2026. 3. Use of PRN psychotropic medications and associated documentation will be reviewed at least 4 days/week during clinical huddle. 4. ED/HSD.

OAR 411-054-0060 Restraints and Supportive Devices Residential care and assisted living facilities are intended to be restraint free environments. (1) Restraints are not permitted except when a resident's actions present an imminent danger to self or others and only until immediate action is taken by medical, emergency, or police personnel. (2) Supportive devices with restraining qualities are permitted under the following documented circumstances: (a) The resident specifically requests or approves of the device and the facility has informed the individual of the risks and benefits associated with the device; and (b) The facility registered nurse, a physical therapist or occupational therapist has conducted a thorough assessment; and (c) The facility has documented other less restrictive alternatives evaluated prior to the use of the device; and (d) The facility has instructed caregivers on the correct use and precautions related to use of the device. (3) Supportive devices with restraining qualities may be utilized for residents who are unable to evaluate the risks and benefits of the device when sections (2)(b), (2)(c) and (2)(d) have been met. (4) Documentation of the use of supportive devices with restraining qualities must be included in the resident service plan and evaluated on a quarterly basis. Stat. Auth.: ORS 410.070 & 443.450 Stats. Implemented: ORS 443.400 - 443.455, 443.991 Hist.: SPD 14-2007, f. 8-31-07, cert. ef. 11-1-07

Based on observation, interview and record review, it was determined the facility failed to ensure the facility RN, a PT, or an OT conducted a thorough assessment of a device with restraining qualities, the use of the device was included in the resident’s service plan, and the facility instructed caregivers on the correct use and precautions related to the use of the device, for 1 of 1 sampled resident (#1) with devices with restraining qualities. Findings include, but are not limited to: Resident 1 moved into the assisted living facility in 07/2024 with diagnoses including ataxia (lack of coordination and unsteady movements). During the acuity interview on 03/02/26, Resident 1 was identified as using a recliner. The resident’s clinical record from 12/03/25 through 03/02/26 was reviewed, observations and interviews with Resident 1 were made, and staff were interviewed. The following was identified: The resident’s 12/08/25 service plan indicated Resident 1 needed stand-by assist for transfers, was a high fall risk, and needed assistance with ADL care including toileting. A change of condition evaluation on 01/14/26 noted Resident 1’s cognition was moderately impaired, s/he was impulsive and had a poor short-term memory. Observations and interviews with Resident 1 identified s/he preferred to spend his/her awake time in the recliner with staff reclining the resident at a variety of angles. Staff were observed providing the chair controller to the resident after the legs were elevated. On 03/04/26, at 1:10 pm the surveyor asked the resident to demonstrate how to lower the legs of the chair to prepare to stand up. The resident pushed the chair controller buttons but acknowledged s/he was not sure how to operate the chair and was not successful in lowering the legs. In this latter instance, the resident’s ability to move freely was limited. Interviews with staff on 03/04/26 and 03/05/26 indicated the resident could “usually” use the chair controller to raise or lower the footrest of the chair and did not recall instances of the resident getting out of the chair when the footrest were still in the up position. Review of the resident's record showed no documented assessment of the recliner as a device with restraining qualities by a facility RN, a PT, or an OT. The resident’s 01/14/26 service plan did not provide information to staff related to the recliner including how to use the device with the resident and safety/maintenance items to watch for. During an interview on 03/04/26 at 1:45 pm, Staff 1 (ED) acknowledged no assessment had been completed for Resident 1’s recliner chair. On 03/04/26 at 3:30 pm, Staff 1 provided an assessment for a “Supportive Devices Assessment” dated 03/04/26, completed by Staff 3 (RN Consultant). The need for a RN, PT or OT to complete an assessment of any device with restraining qualities was discussed Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Resident # 1 supportive device assessment was completed by the RN on 3/5/26. 2. The HSD/designee will audit for supportive device use and ensure that these are either referred to the RN for the initial assessment, or update them by 4/30/2026 for all residents that have these. The HSD will also ensure that these are on the service plans 3. The supportive device evaluation will be reviewed and updated by the HSD/designee at least quarterly. The ED will audit the supportive device evaluations at least quarterly for completion. 4. ED/HSD

OAR 411-054-0070 (1) Staffing Requirements and Training: Staffing (Amended 6/9/21)(1) STAFFING REQUIREMENTS. Facilities must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Direct care staff provide services for residents that include assistance with activities of daily living, medication administration, resident-focused activities, supervision, and support.(a) If a facility employs universal workers whose duties include other tasks (e.g., housekeeping, laundry, food service), in addition to direct resident care, staffing must be increased to maintain adequate resident care and services.(b) Prior to providing care and services to residents, direct care staff must be trained as required in sections (2) - (4) of this rule.(c) The following facility employees are ancillary to the caregiver requirements in this section:(A) Individuals whose duties are exclusively housekeeping, building maintenance, clerical, administrative, or food preparation.(B) Licensed nurses who provide services as specified in OAR 411-054-0045 (Resident Health Services).(C) Administrators.(d) The Department retains the right to require minimum staffing standards based on acuity, complaint investigation or survey inspection.(e) Based on resident acuity and facility structural design there must be adequate direct care staff present at all times, to meet the fire safety evacuation standards as required by the fire authority or the Department.(f) The licensee is responsible for assuring that staffing is increased to compensate for the evaluated care and service needs of residents at move-in and for the changing physical or mental needs of the residents.(g) A minimum of two direct care staff must be scheduled and available at all times whenever a resident requires the assistance of two direct care staff for scheduled and unscheduled needs.(h) In facilities where residents are hosed in two or more detached buildings, or if a building has distinct and segregated areas, a designated caregiver must be awake and available in each building and each segregated area at all times.(i) Facilities must have a written, defined system to determine appropriate numbers of direct care staff and general staffing based on resident acuity and service needs. Such systems may be either manual or electronic.(A) Guidelines for systems must also consider physical elements of a building, use of technology if applicable and staff experience.(B) Facilities must be able to demonstrate how their staffing systems work.

Based on interview and record review, it was determined the facility failed to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: 1. On 03/02/26, the facility’s Acuity-Based Staffing Tool (ABST) information was downloaded for review. The total ABST time indicated the following minimum number of staff required: * Day shift: 8.001 or over eight direct-care staff; * Evening shift: 7.177 or over seven direct-care staff; and * Night shift: 2.215 or over two total direct-care staff. On 03/03/26, the “ABST Facility Entrance Questionnaire” noted the following staffing levels: * Day shift: 8 direct-care staff; * Evening shift: 5.5 direct-care staff; and * Night shift: 4 direct-care staff. A review of the staffing schedule and staff timecards, from 02/02/26 through 02/08/26, revealed seven of 21 shifts, or 33.33% of the shifts reviewed, were not staffed to meet the total ABST generated time. On 03/06/26 at 8:29 am, the above discrepancies were reviewed with Staff 1 (ED) and Staff 2 (Nursing Director/LPN). Staff 1 confirmed they were not staffing to the ABST generated time and did not have a system in place to capture the unscheduled needs of each resident. The need to ensure a sufficient number of direct care staff were present at all times to meet the 24-hour scheduled and unscheduled needs of each resident was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings. 2. During the survey, the facility’s call system was observed to include manually operated call boxes in resident units and common area bathrooms and call pendants worn by multiple residents. When a resident engaged the system, an alert was sent to a computer in a staff area near the front entrance to the facility. Staff who were aware of the alert would alert other staff of calls for assistance via two-way radio. Throughout the survey from 03/02/06 through 03/06/26, observations and interviews with staff and residents revealed the following: * Call system response times were "way too long, often over 20 minutes”; * “I don’t even really call for help anymore, they answer too late”; * Staff were not able to respond to call lights in a "timely manner"; and * When there were no staff present at the workstation near the call system computer, staff were not made aware of resident calls for assistance. Resident 5 was admitted to the facility in 10/2023 with diagnoses including diabetes and hypertension. The resident was interviewed on 03/02/26 at 12:10 pm and reported it typically took about 20 minutes for staff to respond when s/he pressed the call light. Then, suggested to initiate the call light to check how long it would take for staff to respond. Resident 5’s call light was initiated at 12:16 pm and not answered until 12:52 pm. At 12:52 pm Staff 20 (Resident Assistant) answered the call light. Surveyor asked how she knew the resident needed assistance, and Staff 20 stated she saw the call light notification at the front desk. On 03/02/26 at 1:30 pm, Staff 1(ED) stated normally the receptionist would notify staff of call lights, and in the evening and during the night a staff member was assigned to check. She acknowledged the system was outdated. Call system logs from 02/05/26 through 03/05/26 for Residents 1, 2, 4 and 5 were requested and reviewed on 03/05/26 at 1:25 pm. The review revealed call system response times were greater than 20 minutes on 57 occasions. On 03/06/26 at 11:45 am, the need to meet residents’ 24-hour unscheduled needs including ADL care and lengthy response time to call for assistance were discussed with Staff 1. She acknowledged the findings and stated she had placed an order for staff pagers during the survey.

1. The ED and HSD will be educated by the RDHS by 4/10/2026 on how to staff per the ABST and account for unscheduled resident needs. 2. The ED/HSD/RDHS will conduct an audit of the ABST and Staffing levels to ensure sufficient staff are available to meet resident scheduled and unscheduled care needs in accordance with the ABST by 4/10/2026. The call system is being addressed and is scheduled for a new system install (Date TBD). A person will continue to be staffed at the reception desk 24/7 to alert staff to call lights until the system is repaired/replaced. 3. The ED will complete an audit of the ABST tool and update it accurately per resident needs by 4/20/2026. The ED will update and post a corrected staffing plan by 4/20/2026. The ABST will be updated by the ED/HSD/Designee prior to move in, quarterly and with any change of condition. The ED will update the posted staffing plan with changes in the ABST. 4. The Executive Director

OAR 411-054-0037 (4-6) Acuity Based Staffing Tool - Updates & Staffing Plan (4) FREQUENCY OF UPDATES. Facilities must complete or update and review the ABST evaluation for each resident according to the following schedule. (a) Before a resident moves in. (b) Whenever there is a significant change of condition as defined in OAR 411-054-0040(1)(b). (c) No less than quarterly at the same time the resident’s service plan is updated as required by OAR 411-054-0034. (5) DEVELOP AND MAINTAIN UPDATED POSTED STAFFING PLAN. Each facility should use the results of an ABST to develop and routinely update the facility’s posted staffing plan. The staffing plan must outline the staffing numbers required to meet the scheduled and unscheduled needs of all residents in the facility, for each shift. The ABST and staffing plan must be reviewed at the frequency required in paragraph (4) of this rule. The facility must review the following and ensure accuracy between the posted staffing plan and ABST: (a) The total ABST care time required for the individual care elements as referenced in paragraph (3) of this rule. (b) Staffing plan must account for unscheduled care needs. (c) Documentation of consistently staffing to meet or exceed the posted staffing plan 24 hours a day, seven days a week. (d) The staffing requirements outlined in OAR 411-054-0070(1). (e) Any other applicable factors to be considered. (e.g., disruptions to normal facility operations.) (f) Time for paid or unpaid staff meal breaks must be accounted for and should not be included in the total scheduled staff time per shift. (g) Distinct posted staffing plans for segregated areas as outlined in OAR 411-054-0070(1) to meet the scheduled and unscheduled needs of residents who reside in each segregated area. (h) The staffing needs required under the Specific Needs Contracts, if applicable. (6) ABST REPORTING OF SPECIFIC NEEDS CONTRACTS AND EXCEPTIONAL PAYMENTS. Staffing required by a Specific Needs Contract (Contract), as described in OAR chapter 411, division 027, must be included in a facility’s ABST. (a) If all residents within the facility are receiving service through a Contract: (A) The facility’s staffing plan must include the number of staff required by the Contract and additional staff time, if required to meet the scheduled and unscheduled needs of the residents. (B) If the ABST staffing analysis indicates numbers higher than the Contract, the facility must staff to the numbers indicated by the ABST. (b) If certain residents within the facility are served under Contract, and other residents are not served by a Contract: (A) The facility must maintain a posted staffing plan that includes the staffing required for residents served by the Contract as well as the staffing required for residents not served by the Contract. (B) The facility must prepare two distinct ABST reports: one for residents served by the Contract and the other for residents not served by the Contract. (C) If the ABST indicates higher staffing numbers than the Contract for residents who are served by the Contract, the facility must staff to numbers indicated by the ABST. (c) If the facility has any residents funded by an exceptional payment, as provided in OAR 411-027-0050, that must be included in the ABST and the facility must staff to the greater of the exception or the ABST.

Based on observation, interview, and record review, it was determined the facility failed to use the results of the Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's posted staffing plan. Findings include, but are not limited to: On 03/02/26 at 9:26 am, when survey entered the facility, the posted staffing plan was observed at the reception desk and noted “Starting February 17, 2025”: * “Day: 6am-2pm” – noted a total of seven direct-care staff; * “Eve: 2pm-10pm” – noted a total of six direct-care staff; and * “NOC: 10pm-6am” – noted a total of three direct-care staff. On 03/02/26, the results of the facility ABST, including all three floors on each shift, indicated the following staffing levels: * Day shift – 60.02 hours, totaling 8.001 direct-care staff; * Eve shift – 53.83 hours, totaling 7.177 direct-care staff; and * NOC shift – 16.14 hours, totaling 2.215 direct-care staff. The facility failed to use the results of the ABST to routinely update the posted staffing plan. On 03/06/26 at 8:29 am, the above information, including the posted staffing plan last updated on 02/17/25, and the staffing level discrepancies between the posting staffing plan and the ABST-generated staffing level, was reviewed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN). Staff 1 confirmed the last update to the posted staffing plan was in February 2025 and acknowledged the discrepancies between the posted staffing plan and the ABST-generated staffing levels. The need to ensure the facility used the results of the ABST to develop and routinely update the posted staffing plan was reviewed with Staff 1 on 03/06/26 at 11:30 am. She acknowledged the findings.

1.The posted staffing plan was reviewed and updated to ensure it reflects current staffing levels based on the state ABST tool. A current staffing plan has been generated, printed, and posted to accurately reflect staffing requirements by the ED on 4/1/2026. 2. The ED and HSD will be educated by the RDHS by 4/10/2026 on how to staff per the ABST and account for unscheduled resident needs, and how to update the staffing plan with the most current date, and keep historical postings. 3. The ED/Designee will review the ABST weekly x 4 weeks, bi-weekly x 4 weeks and then each time an update is made to the ABST to review/update the staffing plan posting as needed. The results of the ABST/staffing plan review will be reported to the monthly Continuous Quality Improvement committee. 4. The Executive Director

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 4 of 4 newly-hired staff (#s 12, 16, 17, and 18) completed all required pre-service orientation training and 3 of 3 newly-hired direct care staff (#s 12, 17, and 18) completed required pre-service dementia training. Findings include, but are not limited to: Staff training records were reviewed on 03/05/26 at 11:30 am with Staff 4 (Business Office Director), and the following was identified: a. There was no documented evidence Staff 12 (Medication Assistant), Staff 16 (Dining Staff), Staff 17 (Medication Assistant), or Staff 18 (Resident Assistant), hired 12/15/25, 12/29/25, 01/19/26, and 12/08/25, respectively, had completed one or more of the following required pre-service orientation topics prior to beginning their job responsibilities: * Resident rights and values of CBC care; * Abuse reporting requirements; * Written job description; * Infectious disease prevention training; * Home and Community-Based Services training; and * LGBTQIA2S+ training. b. There was no documented evidence Staff 12, Staff 17, and Staff 18 had completed one or more of the following pre-service dementia care training topics prior to beginning their job responsibilities: * Dementia disease process including progression, memory loss, psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to behaviors; reducing use of antipsychotics; * Strategies for addressing social needs and engaging them in meaningful activities; and * Specific aspects of dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach. The need for staff to complete all required pre-service orientation training and for direct care staff to complete required pre-service dementia training was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Staff #’s 12, 16, 17, and 18 will complete the required pre-service training by 4/20/2026. Staff #’s 12, 17, and 18 will complete their pre-service dementia training by 4/20/2026. 2. The ED/BOM audited training records of all current staff. Any identified missing training will be completed by 5/5/2026. Any staff that have not completed the training by then will be removed from the schedule by the ED until it is completed. 3. The BOM/ED/designee will audit all new hires training prior to them working on the floor. 1 staff file will be audited at least 4 days per week at the daily stand up by the BOM. The ED will audit 10% of employee files/training records each month and report to the monthly Continuous Quality Improvement Committee the results of the audits. 4. The Executive Director /BOM

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff (5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF. (a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned. (b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to: (A) The role of service plans in providing individualized resident care. (B) Providing assistance with the activities of daily living. (C) Changes associated with normal aging. (D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition. (E) Conditions that require assessment, treatment, observation and reporting. (F) General food safety, serving and sanitation. (G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised. (9) ADDITIONAL REQUIREMENTS. Staff: (a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services. (b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required. (c) Must have 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. (10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule. (a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 sampled newly-hired staff (#s 12, 17 and 18) demonstrated competency in all assigned job duties within 30 days of hire and 2 of 3 sampled newly-hired staff (#s 17 and 18) lacked documented evidence they had completed first aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 03/05/26 at 11:30 am with Staff 4 (Business Office Director) and revealed the following: a. Staff 12 (Medication Assistant), Staff 17 (Medication Assistant), and Staff 18 (Resident Assistant), hired 12/15/25, 01/19/26, and 12/08/25, respectively, lacked demonstrated competency in all assigned job duties within 30 days of hire in one or more of the following areas: * Role of service plans in providing individualized care; * Changes associated with normal aging; * Identification, documentation, and reporting of changes of condition; * Conditions which require assessment, treatment, observation, and reporting; and * Other duties as applicable (med pass, treatments). b. There was no documented evidence Staff 17 and Staff 18 completed first aid and abdominal thrust training within 30 days of hire. The need for staff to demonstrate competency in their assigned job duties within 30 days of hire was discussed with Staff 1 (ED) and Staff 2 (Director of Nursing/LPN) at 12:15 pm on 03/06/26. They acknowledged the findings.

1. Staff #s 12, 17, and 18 competency records were completed on 4/10/2026 by the HSD. 2. The ED/HSD audited all staff records for competencies. Any identified missing competencies will be completed by 4/30/2026. 3. The BOM/Designee will track return of the staff competency checklists after 3 days of training on the floor. An audit of 10% of employee files will be conducted by the ED monthly and results will be reported to the monthly Continuous Quality Improvement Committee. 4. The ED/HSD

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety (1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded every other month, a written record documented all required components of the fire drill, and fire and life safety instruction was provided to staff on alternate months of fire drills and in accordance with the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and life safety records from 10/2025 through 02/2026 were reviewed on 03/03/26. The following deficiencies were identified: a. Fire drills lacked the following required components: * Fire drills were not conducted every other month; and * Fire drills that were completed lacked documentation related to the escape route used and problems encountered with residents who declined to participate in the drill and what changes were made to ensure the facility could meet the evacuation standard. b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills. In an interview on 03/04/26 at 11:50 am, Staff 6 (Environmental Services Director) reported the facility had not conducted fire drills and recorded each required component at least every other month and did not provide fire and life safety instruction to staff on alternate months of fire drills. The need to ensure fire drills were conducted at least every other month and included a record of each required component and fire and life safety instruction was provided to staff on alternate months of fire drills was discussed with Staff 1 (ED) on 03/06/26 at 11:45 am. She acknowledged the findings.

1.The RDHS will educate the ED/HSD on fire drill requirements and components related to documentation and training requirements by 4/10/2026. 2. By 4/13/2026 the Maintenance Director will be educated by the Executive Director on the requirements of fire drills and the associated components required for documenation. Drills will be held monthly on alternating shifts, and every other month will include a training on fire safety. 3. The ED/designee will audit the monthly fire drill form for completeness. This will be reported on the monthly Continuous Quality Improvement minutes. 4. Maintenance Director/ED

OAR 411-054-0070 (3)(b)(A)(B)(C) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) Facilities must select the LGBTQIA2S+ training to be used by the facility by either: (i) Choosing to use the standard Department-approved biennial LGBTQIA2S+ training, or (ii) Applying to the Department to request approval of a biennial LGBTQIA2S+ training to be provided by the facility. (C) ORS 441.116 requires all LGBTQIA2S+ trainings address: (i) Caring for LGBTQIA2S+ residents and residents living with human immunodeficiency virus. (ii) Preventing discrimination based on a resident’s sexual orientation, gender identity, gender expression or human immunodeficiency virus status. (iii) The defined terms commonly associated with LGBTQIA2S+ individuals and human immunodeficiency virus status. (iv) Best practices for communicating with or about LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including the use of an individual’s chosen name and pronouns. (v) A description of the health and social challenges historically experienced by LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including discrimination when seeking or receiving care at care facilities and the demonstrated physical and mental health effects within the LGBTQIA2S+ community associated with such discrimination. (vi) Strategies to create a safe and affirming environment for LGBTQIA2S+ residents and residents living with human immunodeficiency virus, including suggested changes to care facility policies and procedures, forms, signage, communication between residents and their families, activities, in-house services and staff training. The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule.

Based on interview and record review, it was determined the facility failed to ensure pre-service orientation was completed prior to providing services to residents, including the Department-approved LGBTQIA2S+ course, for 3 of 4 newly hired staff (#s 12, 16, 17 and 18) whose training records were reviewed. Findings include, but are not limited to: Refer to C370.

1.Staff #s 12, 16, 17 and 18 will complete their LGBTQIA2AS+ training by 4/20/2026. 2. The ED/BOM audited training records of all current staff. Any identified missing LGBTQIA2S+ will be completed by 5/5/2026. Any staff that have not completed the training by then will be removed from the schedule by the ED until it is completed. 3. The BOM/Designee will track the initial and bi-annual requirement of this training. An audit of 10% of employee files will be conducted by the ED monthly and results will be reported to the monthly Continuous Quality Improvement Committee 4. ED/BOM

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: The facility's kitchen was toured on 06/09/25 at 9:52 am. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in or underneath the following: * Baseboards and flooring throughout the kitchen; * Walls throughout the kitchen; * Counters throughout the kitchen; * Lighting fixtures throughout the kitchen; * Open shelving under drink stations; * Microwaves; * Toaster; * Sandwich press; * Interior casing of can opener; * Shelving under steam table; * Sides of grill and equipment surrounding grill; * Interior of drawers; * Baker's racks; * Flooring of walk-in refrigerator; * Exhaust fan grates and ceiling in walk-in refrigerator; and * Warewasher, including plumbing and mechanics. b. The following kitchen items required repair or replacement: * Coffee station shelving had cracks, gouges and bare wood exposed; * Exposed area in baseboard under coffee station; * Tea and cocoa station shelving was missing laminate with bare wood exposed; * Microwave interior had peeling enamel; * Green cutting board had gouges and scrapes; * Sandwich press had peeling enamel; * Corner drywall near freezer was gouged with metal corner guard exposed; and * Tile near warewasher was gouged. c. Observation of the facility's refrigerators and dry storage revealed multiple food items were not covered, dated, and/or labeled appropriately. d. Poor infection control practices observed, but not limited to: * Plastic cups, used as scoops, were stored in the containers with the food products; * Stand mixer and mixing bowl were left uncovered when not in use; * Sanitizing buckets had cold water, and kitchen staff were not using chemical testing strips; * Rotten potatoes, moldy blackberries, and wilted greens were observed stored in fresh produce; * Kitchen staff failed to perform hand hygiene consistently between dirty and clean tasks; and * The warewasher was not reaching the required temperature of 120 degrees F. Concerns regarding the warewasher not reaching the minimum temperature for sanitation were discussed with Staff 1 (ED) on 06/09/25 at 11:47 am. The temperature was immediately adjusted and was re-tested at 123 degrees F. A kitchen walkthrough was completed with Staff 1 and Staff 2 (Cook/Dishwasher) on 06/09/25 at 1:51 pm. The areas that did not meet the rules, were discussed with Staff 1 and Staff 2. They acknowledged the findings.

1.All identified areas in the kitchen were thoroughly cleaned in the days following the inspection. This included removal of food debris, spills, grease, and dust from the following areas: • Baseboards and flooring throughout the kitchen • Walls throughout the kitchen • Counters throughout the kitchen • Lighting fixtures throughout the kitchen • Open shelving under drink stations • Microwaves • Toaster • Sandwich press • Interior casing of can opener • Shelving under steam table • Sides of grill and equipment surrounding grill • Interior of drawers • Baker’s racks • Flooring of walk-in refrigerator • Exhaust fan grates and ceiling in walk-in refrigerator The microwave and sandwich press were removed and replaced with new equipment. Damaged cutting boards were discarded and replaced. The drink station, which includes shelving with cracks, gouges, and exposed wood, is currently pending replacement and a vendor quote is being obtained. Other damaged areas, including gouged tile and drywall, are being assessed for appropriate repair or resurfacing. All improperly stored, uncovered, or unlabeled food items were discarded at the time of the inspection. Plastic cups that had been used as scoops were immediately removed and discarded. Staff were re-educated on infection control expectations, including proper hand hygiene when transitioning between dirty and clean tasks. The stand mixer now has a cover in place, and staff were instructed to keep it covered at all times when not in use. Sanitizing buckets were found to be filled with cold water and not tested for chemical strength. Staff were re-educated on correct sanitizing procedures, including maintaining temperature and testing with chemical strips, which were available but not being utilized. Spoiled produce—including blackberries, potatoes, and wilted greens—was discarded. The warewasher was found to be operating below the required sanitation temperature; the water heater was adjusted during the inspection and the warewasher was confirmed to be reaching 120°F. 2. A full inspection of the kitchen and food service areas will be completed prior to the plan of correction compliance date to ensure no other deficient practices exist beyond those identified during the survey. Any additional findings will be addressed and corrected at that time. Although no other staff were cited for infection control concerns, a monthly kitchen staff meeting has been scheduled on an ongoing basis to review sanitation expectations, address any concerns, and reinforce key food safety and infection control policies. As an added layer of oversight, the facility has updated its cleaning checklists and implemented a structured walkthrough schedule: daily walkthroughs by the cook on duty, weekly walkthroughs by the lead cook/dining services coordinator/designee, and monthly walkthroughs by the Executive Director/designee—or more often if concerns arise. 3. Daily, weekly, monthly and as needed for concerns. 4. Cooks, Lead Cook, Dining Services Coordinator, Executive Director, or Designees

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule (1) The residential care or assisted living facility must provide a minimum scope of services as follows: (a) Three daily nutritious, palatable meals with snacks available seven days a week, in accordance with the recommended dietary allowances found in the United States Department of Agriculture (USDA) guidelines, including seasonal fresh fruit and fresh vegetables; (A) Modified special diets that are appropriate to residents' needs and choices. The facility must encourage residents' involvement in developing menus. (B) Menus must be prepared at least one week in advance, and must be made available to all residents. Meal substitutions must be of similar nutritional value if a resident refuses a food that is served. Residents must be informed in advance of menu changes. (C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: The facility's kitchen was toured on 08/20/25 at 9:00 am. a. An accumulation of food spills, splatters, loose food debris, grease, dirt, dust, garbage, or black matter was observed on, in, or underneath the following: * Tile flooring/grout lines/cove base at kitchen entrance and throughout the kitchen; * Metal edge of hand wash sink and white half wall adjacent to coffee area; * Caulking behind hand wash sink; * Floor drain near ice machine; * Multiple walls throughout the kitchen; * Open shelving and bins under drink stations; * Microwave at tea/cocoa station; * Shelving under steam table; * Sides of grill and equipment surrounding grill; * Baker's racks; * Flooring of walk-in refrigerator; * Exhaust fan grates and ceiling in walk-in refrigerator; and * Caulking and wall underneath dish machine. b. The following kitchen items required repair or replacement: * Baseboard under coffee station; * Tea and cocoa station shelving had laminate taped to the edge; * Corner drywall near freezer was gouged, with metal corner guard exposed; * Tile near dish machine was gouged; * Paint on entry/exit doors was scratched; and * Scraped/gouged wall behind food bins. c. Two kitchen staff did not have facial hair contained/covered. A kitchen walk-through was completed with Staff 1 (Executive Director) on 08/20/25 at 10:15 am. She acknowledged the findings.

1. The kitchen flooring, including tile, grout lines, cove base, and walk-in refrigerator floors, was steam cleaned and power washed, with regular steaming added to the cleaning schedule. The metal edge of the hand wash sink and adjacent half wall were thoroughly cleaned. Caulking behind the hand wash sink was cleaned, and sections that could not be adequately sanitized were replaced. Floor drains near the ice machine were fully cleaned. All walls, open shelving, bins, the microwave, shelving under the steam table, grill sides and surrounding equipment, and baker’s racks were cleaned and sanitized. Exhaust fan grates and the ceiling in the walk-in refrigerator were dusted and cleaned. The caulking and wall underneath the dish machine were cleaned, with replacement performed where cleaning was not sufficient. The coffee, tea, and cocoa station was scheduled to be resurfaced, and the area underneath was enclosed to ensure smooth and cleanable surfaces. Drywall near the freezer was patched and repainted, restoring the integrity of the wall. Gouged tile near the dish machine was repaired. Scratched paint on the entry and exit doors was touched up, and scraped walls behind the food bins were patched and painted to create intact and easily sanitized surfaces. Beard nets were purchased and distributed to all kitchen staff, and all staff received immediate re-education on personal hygiene requirements and food sanitation standards. Supervisory spot checks were initiated to verify compliance with facial hair covering at the beginning of each shift. 2. To correct the system and prevent future violations, the facility has implemented comprehensive cleaning checklists that address each specific area cited, including floors, grout, drains, walls, shelving, equipment surfaces, and refrigeration units. These checklists are divided into daily, weekly, and monthly tasks to ensure consistent attention to both high-use and hard-to-reach areas. All cleaning is logged by staff and reviewed by supervisory personnel for accountability. In addition, a preventive maintenance program has been established to identify and promptly repair damaged or uncleanable surfaces such as drywall, tile, paint, and shelving. Staff hygiene compliance is now monitored through mandatory beard net use, reinforced by staff education, updated dress code policy, and supervisory spot checks at the start of each shift. These system corrections create multiple layers of oversight to maintain sanitation, ensure repairs are completed in a timely manner, and sustain compliance with food sanitation rules. 3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained. 4. Executive Director, Dining Services Coordinator, or Designee

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 staff (#s 2 and 4) who prepared food had active food handler's certificates. Findings include, but are not limited to: On 06/09/25, employee records were requested and reviewed to ensure staff had active food handler's cards. The food handler's cards for Staff 2 (Cook/Dishwasher) and Staff 4 (Cook/Dishwasher) were dated as obtained the day of survey. On 06/09/25 at 2:31 pm, the surveyor requested to review Staff 2 and Staff 4’s previous food handler's cards. Staff 1 (ED) reported she “couldn’t track them down.” The need to ensure staff who prepared food had active food handler’s certificates was discussed with Staff 1 on 06/09/25 at 2:31 pm. She acknowledged the findings.

1. All food service employees have obtained current food handler certifications. The Business Office Coordinator (BOC) is now responsible for tracking food handler card documentation and monitoring expiration dates. Staff will be notified in advance of any upcoming expirations to ensure continuous compliance. Certification records will be stored in the Training Binders located in the business office. Moving forward, food handler certification will be required as part of the onboarding process for all new food service employees. The BOC will review the training tracker at least twice per month to confirm that all required documentation remains up to date. 2. To ensure that no additional staff were out of compliance, a full audit of employee files was completed, and all food service staff were confirmed to have valid food handler certifications. All current documentation is now stored centrally in the Training Binders and monitored by the Business Office Coordinator to prevent future lapses. 3. Twice monthly review of the Training Tracker for food handler's cards expiring and as needed for new hires by Business Office Coordinator. Executive Director will verify at least quarterly to ensure tracker is up-to-date and compliant. 4. Business Office Coordinator and Executive Director

OAR 411-054-0070 (3-4) Staffing Requirements and Training – Pre-service (3) PRE-SERVICE ORIENTATION FOR ALL EMPLOYEES. Prior to beginning their job responsibilities, all employees must complete orientation training regarding: (a) A review of their written position description with their job responsibilities. (b) RESIDENTS’ RIGHTS. Residents' rights and the values of community-based care, including the Department-approved LGBTQIA2S+ trainings. (A) Effective December 31, 2024, all staff must have completed the required training. All new staff, hired on and after January 1, 2025, must complete the required training prior to beginning job responsibilities. (B) The Department-approved LGBTQIA2S+ trainings shall address the elements described in paragraph (6)(b) of this rule. (c) Abuse and reporting requirements. (d) Fire safety and emergency procedures. (e) INFECTIOUS DISEASE PREVENTION. Prior to beginning their job responsibilities, unless the employee received the training described below within the 24-month period prior to the time of hiring, all employees must complete training addressing the prevention, recognition, control and reporting of the spread of infectious disease. (A) The Department, in consultation with the Oregon Health Authority, has determined this training must address the following curricula: (i) Transmission of communicable disease and infections, including development of a policy with criteria directing staff to stay home when ill with a communicable disease, so as not to transmit disease. (ii) Policy addressing respiratory hygiene and coughing etiquette. (iii) Standard precautions. (iv) Hand hygiene. (v) Use of personal protective equipment. (vi) Cleaning of physical environment, including, but not limited to disinfecting high-touch surfaces and equipment, and handling, storing, processing and transporting linens to prevent the spread of infection. (vii) Isolating and cohorting of residents during a disease outbreak. (viii) Employees must also receive training on the rights and responsibilities of employees to report disease outbreaks under ORS 433.004 and safeguards for employees who report disease outbreaks. (B) INFECTIOUS DISEASE TRAINING CURRICULUM. Pre-service infectious disease training curriculum must be approved by the Department before facilities may offer training to staff. (i) The pre-service training may be provided in person, in writing, by webinar or by other electronic means. (ii) Facilities or other entities that want to provide training curriculum to facilities must first present that curriculum to the Department for review and approval. (f) HOME AND COMMUNITY-BASED SERVICES (HCBS) TRAINING. All staff are required to complete the Department-approved HCBS training, as provided below: (A) Effective March 31, 2024, all staff must have completed the required training. (B) All new staff, hired on or after April 1, 2024, must complete the required training prior to beginning job responsibilities. (g) FOOD HANDLING. If the staff member's duties include preparing food, they must have a food handler's certificate. (4) PRE-SERVICE TRAINING FOR ALL DIRECT CARE STAFF. (a) DEMENTIA. Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (A) Documentation of dementia training: (i) A certificate of completion shall be issued to direct care staff who satisfactorily complete approved dementia training. Facilities shall also maintain records of all direct care staff who have successfully completed pre-service dementia training. (ii) Each facility shall maintain written documentation of continuing education completed, including required pre-service dementia training, for all direct care staff. (B) Portability of pre-service dementia training: After completing the pre-service training, if a direct care staff person is hired within 24 months by a different facility, the hiring facility may choose to accept the previous training or require the direct care staff to complete the hiring facility’s pre-service dementia training. (C) A certificate of completion must be made available to the Department upon request. (D) Pre-service dementia care training must include the following subject areas: (i) Education on the dementia disease process, including the progression of the disease, memory loss, and psychiatric and behavioral symptoms. (ii) Techniques for understanding, communicating, and responding to distressful behavioral symptoms, including, but not limited to, reducing the use of antipsychotic medications for non-standard uses. (iii) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities. (iv) Information concerning specific aspects of dementia care and ensuring the safety of residents with dementia, including, but not limited to, how to: (I) Identify and address pain. (II) Provide food and fluids. (III) Prevent wandering and elopement. (IV) Use a person-centered approach. (b) ORIENTATION TO RESIDENT. Pre-service orientation to resident: (A) Prior to providing personal care services for a resident, direct care staff must receive an orientation to the resident, including the resident’s service plan. (B) Direct care staff members must be directly supervised by a qualified person until they have successfully demonstrated satisfactory performance in any task assigned and the provision of individualized resident services, as applicable

OAR 411-054-0105 (2-4) Inspections and Investigation: Insp Interval (Amended 12/15/21)(2) The facility shall not interfere with a good faith disclosure of information by an employee or volunteer concerning abuse or other action affecting a resident's safety or welfare, as described in OAR 411-054-0028(4).(3) Staff of the Department shall visit and inspect every facility at least but not limited to once every two years for a full in-person survey to determine whether the facility is maintained and operated in accordance with these rules.(a) For each year during which a facility does not have a full survey, the Department shall conduct an in-person inspection of the kitchen and other areas where food is prepared for residents.(b) Subsection (a) will not go into effect until July 1, 2022.(c) Facilities not in compliance with these rules must submit, within ten days of receipt of the inspection report, a plan of correction that satisfies the Department.(d) The Department may impose sanctions for failure to comply with these rules.(4) Department staff may consult with and advise the facility administrator concerning methods of care, records, housing, equipment, and other areas of operation.

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C 240.

1. The facility immediately conducted a full kitchen deep cleaning and verified that all previously cited areas were corrected. Staff were re-educated on their responsibilities under the plan of correction, and updated cleaning and maintenance checklists were implemented. A new plan of correction was written to address all cited issues and ensure regulatory compliance. 2.The facility re-educated staff to ensure the kitchen plan of correction is fully implemented and maintained. Cleaning and maintenance tasks from the POC have been built into daily, weekly, and monthly checklists, with documentation reviewed by the Dining Services Manager and oversight by the Executive Director. 3. The Executive Director, Dining Services Coorintator, or designee will complete a kitchen walk-through each week to verify that cleaning, maintenance, and staff compliance are sustained. 4. Executive Director

Based on observation, interview, and record review, it was determined the facility failed to ensure proper food preparation and food service, proper sanitation of equipment, proper employee infection control and failed to ensure the kitchen was clean and maintained in good repair in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: The facility kitchen was toured on 03/14/24 at 10:37 am. a. The following areas needed cleaning and/or repair: * Kitchen entrance door leading to the dining room had peeling paint; * There was multiple small holes in the wall by the juice/coffee counter and sink; * Laminate veneer on the bottom and corners of the juice/coffee counter were missing with exposed wood, which created an uncleanable surface; * Coffee cups and other glassware housed in the cabinet beneath the juice/coffee counter were not stored in a manner to prevent cross contamination and the clean dishes were observed to have spillage from coffee and/ or juice; * The juice machine had sticky residue buildup on the nozzles and exterior of the machine; * The handwashing sink between the ice machine and juice machine failed to have splash guards; * The window sill at the kitchen entrance had exposed wood rendering the surface uncleanable; * White three drawer plastic bins to the left of the entrance door (that housed single use food items) were visibly dirty on the interior and exterior; * The ice machine had a brown substance buildup around the interior seal and interior electrical cables; * The floor underneath and behind the upright beverage refrigerator, behind the ice machine and Hobart mixer had a build up of food debris and dust; * The spice rack and spice jars hanging on the wall next to the Hobart mixer were visibly dirty and jars were left open to air; * Galaxy conveyor toaster on the steam table was not cleaned and sanitized after use; * The electrical outlet on the steam table was burned out and in need of repair; * The back of the equipment, wall and floor underneath and behind the Vulcan ovens had a build up of food debris and grease; * The legs of the stand holding the Cleveland steamer had buildup of debris and oxidation; * The counter mounted can opener housing and blade had a buildup of food debris; * A large white wire rack hanging on the wall (to left of the steam table) had multiple areas of protective coating that had peeled off and was rusting; * The electrical power strip in the dry food storage area (shared space with managers office) was burned out and need of replacement; * The floor and shelving in the dry food storage area had a build up of food debris, dust and food was housed with personal belongings such as shoes, clothing and purses; * The reach-in freezers had spillage and food debris buildup on the interior shelves and the exterior front and door handles; * Prep table next to the walk-in refrigerator was pulled off the wall bracket and the caulking between the table and wall was missing; * Spice jars on the shelf above the prep table (next to the walk-in refrigerator) were left open to air and were visibly dirty and the black microwave had food debris buildup on the interior; * Walk-in refrigerator door paint on the exterior and interior was peeling off, the door handle was broken and the door was unable to securely close, and the door's gasket surrounding the door was coming off; * The floor and walls of the walk-in refrigerator had a build up of food debris, splatters and an unknown liquid substance; * The caulk adjoining the stainless-steel ware washing area and the wall above and beneath the warewash area had a buildup of black and brown matter and the caulk was deteriorating which caused water to saturate the wall beneath the ware wash counter; * There was a broken drainpipe in the dishwashing area; * A wire rack in the dishwashing area that housed cleaning chemicals was rusted; * A stainless-steel cart in the dishwashing area had areas of rust, including rust on the casters; and * Approximately 12-inch X 12-inch square floor tiles were missing on the floor underneath the sprayer sink in the dishwashing area; and * Multiple food service racks (stainless steel and plastic) had a buildup of debris and were not sanitized prior to use. Observations of food storage identified the following: *The dry food storage area had multiple packages that were left opened to air and items removed from the original packaging that were left open to air without a label or date (jasmine rice, table salt, split peas, various grains etc.); * The walk-in refrigerator had expired produce (multiple heads of lettuce, onions etc.); and * Fish was improperly stored above and next to butter and eggs. Observations of the food preparation and food service identified the following: * Cold food items (milk-based products, fresh cut vegetables, ready to eat meats and cheeses) plated for food service had temperatures above 41 degrees F. when served from the tray line; and * Approximately 22 blocks of butter that contained soy and milk product was stored on a shelf and not maintained below 41 degrees F. Review of infection control practices identified the following: * Staff 1 (Dining Services Coordinator) failed to ensure hair was effectively restrained; * Staff 1, Staff 2 (Cook) and Staff 5 (Dishwasher) failed to have valid Oregon Food Handler cards; * Multiple kitchen staff and direct care staff observed during meal service failed to consistently perform hand hygiene and change gloves between tasks; * Direct care staff assisting during meal service failed to consistently use aprons; * Staff were observed using the eyewash station as a hand washing station; * Staff failed to have and use test strips for testing sanitation buckets used for sanitizing surfaces and failed to change the sanitation buckets at least every two hours or when the water was visibly dirty; and * Trash cans, including compost bins and a recycling bin with food containers that contained food debris lacked covers when not in use. The kitchen was toured, and the above areas were discussed with Staff 1 and Witness 1 (RN Consultant) on 03/14/24 at 1:32 pm. They acknowledged the findings.

1. Kitchen doors were painted. Holes in wall behind juice/coffee counter and sink will be patched and wall will be painted. Counter holding the juice and coffee maker will be replaced. Temporary covers for the glassware in place, with permanent covers to be installed with new counter. Juice machine was cleaned including cleansing the nozzles and exterior of the machines. Splash gaurds for handwashing sink will be installed. Windowsill at kitchen entrance will be repainted. White three drawer plastic bins were cleaned, both interior and exterior. Ice machine was cleaned. Floors will be deep cleaned throughout the kitchen. Spice rack was cleaned, all spice jars were cleaned, and all spices will be covered. Toaster was cleaned and sanitized. Electrical outlet on the steam table will be replaced. Vulcan overs will be deep cleaned including the back of the machine, the wall, and the floor underneath the ovens. Legs of the steamer stand were cleaned. Can opener was cleaned. Wire rack to left of steam table will be replaced/repaired. Power strip in the food storage office was replaced. Dry food storage area was deep cleaned, including the floors and the racks. Personal items were removed from food shelving.  Reach in freezers were cleaned, both interior and exterior. Prep table next to walk in was pushed back against wall and chaulking replaced. Food removed from microwave and disposed of. Walk in walls painted and floors cleaned. Walk in door will be repaired or replaced.  Chaulking around dishwashing area was replaced. Drainpipe in dishwashing area will be replaced or repaired. Wire rack in the dishwashing area will be replaced or repaired. Rust removed from the stainless steel dishcart and casters replaced. Tile will be replaced in dishwashing area. All food service racks cleaned. Dry stored foods will be stored in containers with lids with open dates and labels. Expired food removed from walk-in and food arranged properly on shelves. Cold food items will be stored in the walk-in and only removed when it is time to serve them. Butter will be stored in refrigerated unit. Properly fitting hair nets were obtained. Re-education will be provided to all staff regarding hand hygiene, gloves, aprons, and hair nets by 4/25/24. All kitchen staff will maintain current food handlers cards. Soap dispenser and papertowel dispenser will be removed from eyewash station to prevent it from being used as a handwash station. Test strips will be used for testing sanitation bucks at least every two hours. Trash cans, recycling, and food bins will all have covers when not in use. 2. ED and dietary director to distribute daily, weekly, monthly cleaning checklist. Daily walk through by dietary director, ED, or designee. 3. Dietary director or designee will review checklists daily. ED will also do a daily walkthrough of the kitchen until all is in compliance, then weekly walk throughs. ED to review survey checklist with dietary director during 1:1 weekly meeting. 4. Dietary director and Executive director are responsible for meeting and mainting compliance.

The findings of the kitchen inspection, conducted 03/14/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Sanitation Rules OARS 333-150-0000.

The findings of the revisit to the kitchen inspection of 03/14/24, conducted 05/16/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. Findings include, but are not limited to: Resident 1 was admitted to the facility in 10/12/23 with diagnoses including Type 2 diabetes, seizure disorder, and hypertension. The resident's facility records were reviewed. Resident 1 and staff were interviewed. The following was identified: The move-in documentation, dated 09/28/23, identified the resident as administering his/her medications. A review of Resident 1's physician's orders revealed s/he took medications for mood, gout, cholesterol, blood pressure, pain, seizures, edema, and chest pain. The resident was an insulin dependent diabetic, and had both scheduled and PRN inhalers prescribed for breathing issues. Observations of Resident 1 on 10/16/23 at 3:12 pm and on 10/17/23 at 10:04 am, noted the resident was well groomed, dressed appropriately, cognitively intact, and able to hold a conversation. On 10/17/23 at 10:04 am, Resident 1 confirmed s/he had not had his/her medications since move in. The resident reported s/he was a retired nurse and stated s/he would call staff if s/he was not "feeling right" and needed to go to the hospital. There were 31 sealed moving boxes observed in the resident's room. Resident 1 stated s/he did not know if the medications were in the boxes as the movers "packed all of my belongings." The resident confirmed that s/he was unable to go through the boxes due to his/her health conditions. On 10/17/23 at 10:55 am, Staff 1 (ED) reported staff had contacted her on 10/14/23 stating the resident was requesting the facility to "take over [his/her] medications." She was contacted again the next evening on 10/15/23 at approximately 9:30 pm by another staff member, stating the resident wanted the facility to "do [his/her] meds" as the resident "didn't have any medications with [him/her]." Staff 1 confirmed the process for new admissions. The facility used a checklist that addressed what staff were to do prior to move in, day before move in, and once resident was in the community. The section directing staff on what to do once the resident was in the community addressed the following: * "All medications counted upon receipt and form signed by family"; * "Medications reconciled with [medication list]. Are all medications on hand?" and * "Follow up for medications not on hand". Both Staff 1 and 2 confirmed the facility failed to implement the checklist for Resident 1 and they were not aware the resident did not have his/her medications upon admission. The need for reasonable precautions to be exercised against any condition that could threaten the health, safety or welfare of residents was discussed with Staff 1 and Staff 2 on 10/18/23. They acknowledged the findings.

1. Resident #1's medications were obtained from Kaiser pharmacy Long Term Care Pharmacy on 10/19/2023. 2. Resident's medications will be reviewed to confirm that resident/family has all resident's prescribed medications for resident to self administer or to provide community staff for associate administration. Medications that are not provided from resident/family will be ordered from resident's pharmacy, provided by the family, or ordered from community preferred pharmacy. Medications for all admissions within the last 30 days will be reviewed to ensure all medications are on hand. 3. This process will be completed with each new admission. 4. The Health and Wellness Director/designee will complete each review.

Based on interview and record review, it was determined the facility failed to ensure an injury of unknown cause was promptly investigated and reported to the local SPD office when abuse and/or neglect could not reasonably be ruled out, for 1 of 3 sampled residents (# 4) with incidents that were reviewed. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2023 with diagnoses including anemia and history of falling. A review of the resident's clinical record, including progress notes, between 07/15/23 and 10/16/23, temporary service plans, and staff interviews identified the following: 09/26/23 - A bruise on the resident's upper back on the right side. During an interview on 10/18/23 at 10:30 am, Staff 11 (MT/CG) confirmed Resident 4 was alert and oriented, and s/he would be able to answer questions regarding the cause of the injury. There was no documented evidence the bruise had been investigated to rule out abuse or suspected abuse, nor evidence the local SPD was immediately notified. The need to investigate resident incidents to rule out abuse or suspected abuse, notify the local SPD if abuse could not be ruled out was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. Bruise for Resident #4 identified on 9/26/23 was investigated by Health and Wellness Director and abuse and neglect ruled out. Resident denied abuse and reasonable explination for bruising was determined so injury was not reported to Adult Protective Services (APS). 2. At daily clinical meeting skin report cards will be reviewed for new skin issues. New issues will be investigated and documented. APS will be notified when appropriate. Training provided to new Resident Care Coordinator (RCC) for skin report cards and reporting on new skin issues. Skin report cards reviewed for the last 30 days for any new skin issues; documentation and reported completed as needed. 3. This will be evaluated daily at clinical meeting. 4. Health and Wellness Director and Executive Director, or designee.

Resident 1 was admitted to the facility in 10/2023 with diagnoses including Type 2 diabetes and a seizure disorder. The facility used an "Addendum Questionnaire" and a "Personal Service Assessment" document to evaluate residents prior to admitting to the facility. The resident's documents, dated 09/28/23, were reviewed and lacked the following required elements: * Customary routines including eating; * List of current diagnoses; * List of medications and PRN use; * Visits to health practitioner(s), ER, hospital or Nursing Facility in the past year; * Mental health issues including effective non-drug interventions; * Personality including how the person copes with change or challenging situations; * Ability to use call system; * Housework and laundry; * Pain including non-pharmaceutical interventions and how a person expresses pain or discomfort; * Emergency evacuation ability; * History of dehydration or unexplained weight loss or gain; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including, but not limited to noise, lighting, room temperature. On 10/16/23 at 3:13 pm, Staff 1 (ED) confirmed there was no additional information relating to Resident 1's move-in evaluation. The need to ensure newly admitted resident evaluations included each required element was discussed with Staff 1 and Staff 2 (Health and Wellness Director) on 10/18/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the move-in evaluation contained all required elements for 1 of 1 sampled resident (# 1) whose evaluation was reviewed. Findings include, but are not limited to:

1. Resident evaluation with customary routines and preferences completed for Resident #1 on 10/16/2023. 2. At move in, evaluation will be completed to include but not limited to, areas noted in statement of deficiencies. Quarterly evaluation checklist will be completed with each service plan update to ensure all ancillary evaluations are completed at the time of review. Evaluations reviewed and completed for all resident's admitted in the last 30 days. 3. Review will occur daily at clinical meeting and as part of the quarterly care planning process. 4. Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to evaluate and gather data that was relevant to the needs and current condition of the resident following a significant change of condition, and ensure the evaluation was used as the basis of the resident's service plan for 1 of 4 sampled residents (#9) whose evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 9 was admitted to the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. During the acuity interview on 01/29/24 it was reported the resident was admitted to hospice. Observations, interviews with staff, and review of the most recent evaluation and service plan dated 01/12/24, identified the evaluation wasn't reflective of the resident's current status and condition, and was not utilized as the basis of the resident's service plan in the following areas: * Bathing and level of assistance needed; * Pain and how pain was expressed, including non-pharmacological interventions; * Skin issues, type, treatment and wound care location; * Transportation assistance; * Complex medication regimen; * Falls; and * Outside service providers, including hospice. The need to ensure evaluations were updated, included relevant data related to the resident's current needs and condition with sufficient information to be used to update the service plan was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

1. Resident 9's evaluation was reviewed and updated on 2/23/24 to be consistent with her current needs including: addressing her bathing assistance, detailing her pain and how she expresses pain and non-pharmacological interventions specific to the resident, description of her skin deficits including treatment needs, her transportation needs, her complex medication regimen, her fall history and interventions, and her outside service providers. Additionally, resident evaluations will be reviewed for current needs and preferences and completed by 3/17/24. 2. Evaluations will be reviewed at each service plan meeting and updated with the service plan. The service plan will be reviewed to verify that the plan is consistent with the current level of resident need and aligns with resident's current preferences. Evaluations will also be brought to care conferences to be reviewed by the care planning team and attached to the signed service plan. 3. Evaluations will be updated with each service plan at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition. 4. Executive Director, Health and Wellness Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were readily available to staff, and provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 3 of 6 sampled residents (#s 2, 5, and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted in 06/2023 with diagnoses including sleep apnea, mild neurocognitive disorder, and depression. The resident's 07/15/23 service plan and Temporary Service Plans (TSPs) were reviewed. Resident 6 and staff were interviewed. The following areas were either not reflective on the resident's service plan or lacked clear direction to staff: * The use of a CPAP (continuous positive airway pressure) machine; * How environmental factors impact the resident's behavior; * Behavior interventions relating to the timeliness of medications; and * Where the resident preferred to eat his/her meals. The need to ensure service plans provided clear direction to staff which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 2. Resident 5 was admitted to the facility in 01/2021 with diagnoses including hypertension.   The resident's 08/01/23 service plan and Temporary Service Plans (TSPs) were reviewed and were not reflective of the resident's current needs and lacked clear instruction to the staff in the following areas: * ADL assistance provided by hospice providers; * Assistive mobility devices, use of manual wheelchair; * Treatments, oxygen use; and * Toileting, use of urinal. The need to ensure service plans were reflective of resident needs and included clear instructions to the staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. 3. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe), Type 2 diabetes mellitus with diabetic chronic kidney disease and major depressive disorder. Observations were made of the resident's care on 10/17/23. Interviews with facility staff and the resident were conducted. The current service plan dated 10/03/23 was reviewed. Resident 2's service plan was not reflective of the resident's current needs and lacked clear instructions to staff in the following areas: * Presence of depression and history of treatment; and * Instructions for signs and symptoms of infection to report when providing care to the suprapubic insertion site. The resident's current service plan, dated 10/03/23, was filed in their medical record, which was locked in the medication room and was not readily available to staff. The need to ensure the service plan reflected residents' current needs, provided clear instructions to staff regarding delivery of services, and was readily available to staff was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. Care Plan for Resident 6 was updated 11/10/23  to include use of CPAP, behaviors and contribution of enviromental factors, and eating preferences. Care plan for Resident 2 updated 11/3/23 to include presence of depression and history of treament as well as instructions for monitoring and providing care for suprapubic insertion site. Care plan for Resident 5 was updated 10/23/23 to include ADL assistance provided by hospice, current use of manual wheelchair, oxygen use, and toileting needs. 2. All care plans will be reviewed by care plan team and resident/family to ensure accuracy and updates will be made as needed. Temporary Service Plans (TSPs) and Outside Provider notes will be reviewed at clinical meeting and written onto care plans as appropriate. 3. Daily at clinical meeting and with each care plan update. 4. Health and Wellness Director and Executive Director, or designee.

2. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. Resident 8's service plan dated 01/18/24 was reviewed. Observations and interviews with the resident and staff were conducted during the survey. The service plan was not reflective and did not provide clear caregiving instruction in the following areas: * Nutrition: Weight loss and interventions; * Dressing and grooming: One-versus-two person dressing assistance, oral care, no longer could stand to be weighed, and no longer wore compression socks; * Bathing: Shower assistance vs. bed bath from hospice providers; * Bathroom: one-versus two-person assistance for brief changes and frequency of staff checks per shift; * One-versus two-person transfer assistance; * Skin care: interventions and wound care; and * Hospice comfort care interventions. The need to ensure service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans reflected the resident's needs as identified in the evaluation and provided clear direction to staff, which included a written description of who shall provide the services and what, when, how, and how often the services shall be provided, for 2 of 4 sampled residents (#s 8 and 9) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. The resident's service plan dated 01/12/24 and Temporary Service Plans (TSPs) were reviewed. Observations and interviews with the resident and staff were conducted during the survey. The following areas were not reflective of the resident's current care needs and/or lacked clear direction to staff: * Bathing: Shower assistance vs. bed bath from hospice providers; * Dressing: No indication of who was to assist the resident and how; * Bathroom tasks: No indication of who was to assist the resident and how; * Reluctance to accept care: "was evaluated for hospice but declined admission"; and * Skin care and who provided the wound care treatments. The need to ensure service plans reflected the resident's current care needs and status, provided clear direction to staff, and included a written description of who shall provide the services and what, when, how, and how often the services shall be provided was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings.

1. Resident 9's service plan was updated to reflect resident's needs and provide clear direction to care staff in the following areas: shower assistance, dressing, bathroom tasks, reluctance to accept care, and skin care. Resident 8's service plan was updated on 1/31/24 to reflect her current nutrition needs including staff assistance with feeding, nutritional supplements, and weekly weights. Resident 8's service plan was also updated in the follow areas: dressing and grooming, shower assistance, bathroom assistance, transfer assistance, skin care, and hospice coordination and care. Additionally, service plans will be reviewed by 3/17/24 to confirm they provide clear direction to staff regarding how assistance will be provided and who is responsible to provide it. 2. Service plans will be reviewed and updated as required. Heath and Wellness Director will sign off on service plans at review. Additionally, service plans will be reviewed at care conferences with the entire care planning team to verify the services align with resident's personal preferences. Signatures will be obtained from care planning team at that meeting acknowledging service plans are reflective of resident's current needs/preferences. 3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition. 4. Executive Director, Health and Wellness Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of resident's needs and preferences, provided clear direction regarding the delivery of services, and was implemented for 1 of 3 residents (#12) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 12 was admitted to the facility in 04/2019 with diagnoses including depression, stroke, and arthritis. The resident's 04/28/24 service plan and temporary service plans dated 04/16/24 to 05/28/24 were reviewed, interviews with staff and the resident were conducted, and observations were made. The resident's service plan was not reflective of needs and preferences, did not provide clear direction to staff, and/or was not implemented in the following areas: * Nectar-thick liquids; * Meal assistance; * Nutritional supplement; * Bed positioning; * Suicidal ideation; * Hearing aids; and * Heel boots. The need to ensure service plans were reflective, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED) on 05/29/24. She acknowledged the findings.

1. Resident #12 service plan was updated with the information found in the Statement of Deficency as well as reviewed for any further updates as needed. An audit was performed on service plans to identify residents that had recent changes in condition and/or high levels of care. These care plans were reviewed for accuracy in care performed, staff direction, and addition personalized information regarding the resident. 2. Service plans will be reviewed and updated as required with input from resident, care planning team, and community staff as needed to ensure that they are reflective of resident's current needs, have clear staff direction for cares, and are personalized to suit resident preference and needs. 3. Care Plans will be updated at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition. 4. Executive Director, Health and Wellness Director and/or Designee.

2. Resident 1 was admitted to the facility in 10/12/23 with diagnoses including Type 2 diabetes, seizure disorder, and hypertension. The resident's facility records were reviewed. Resident 1 and staff were interviewed. The following was identified: The move-in documentation, dated 09/28/23, identified the resident as administering his/her medications. A review of Resident 1's physician's orders revealed s/he took medications for mood, gout, cholesterol, blood pressure, pain, seizures, edema, and chest pain. The resident was an insulin dependent diabetic and had both scheduled and PRN inhalers prescribed for breathing issues. On 10/17/23 at 10:04 am, Resident 1 confirmed s/he had not had his/her medications since move in. On 10/17/23 at 10:55 am, Staff 1 (ED) reported that staff had contacted her on 10/15/23 at approximately 9:30 pm by staff, stating the resident wanted the facility to "do [his/her] meds" as the resident "didn't have any medications with [him/her]." On 10/17/23 at 10:55 am, Staff 1 and 2 (Health and Wellness Director) confirmed the resident had not been monitored for missing his/her medications since the time of the move in. The need to ensure changes of condition were evaluated, actions or interventions were determined, those actions or interventions were communicated to staff on each shift, and documented on through resolution was discussed with Staff 1 and Staff 2 on 10/18/23. They acknowledged the findings. 3. Resident 6 was admitted to the facility in 06/2020 with diagnoses including sleep apnea, mild neurocognitive disorder, and depression. The resident's progress notes, dated 07/17/23 through 10/14/23, and Temporary Service Plans (TSPs) were reviewed. Staff were interviewed. The following changes of condition were identified: * 09/21/23 - new medication, docusate (for constipation), was started and staff were directed to monitor for nausea, vomiting, abdominal pain, cramps, diarrhea, and loose stools; * 10/03/23 - suicide ideation's were documented and staff were directed to monitor and report for increased isolation, and hallucinations (both auditory and visual); and * 10/04/23 - new medication, fexofenadine (for allergies), was started and staff were directed to monitor for rash, dizziness, nausea, vomiting, diarrhea, loose stools, hives, and trouble breathing or swallowing. There was no documented evidence Resident 6 was monitored with weekly progress noted through resolution. The need to ensure changes of condition were documented on at least weekly with progress noted until the conditions resolved was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. No additional information was received.

Based on observation, interview, and record review, it was determined the facility failed to determine what actions or interventions were needed, ensure actions or interventions were communicated to staff on each shift, and documented at least weekly with progress noted until the condition resolved for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5 and 6), who experienced changes of condition. Resident 5 experienced ongoing falls. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 01/2021. The resident had a diagnoses of hypertensive heart failure and was admitted to hospice in 07/2023. a. Interviews and reviews of the resident's progress notes dated 07/09/23 through 10/19/23, 08/01/23 service plan, temporary service plans, Hospice Provider Collaboration notes and incident reports revealed the following: * On 08/10/23, Resident 5 experienced a fall in his/her unit resulting in pain to his/her back. There was no documented evidence the facility determined and documented any actions or interventions related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 08/11/23, the resident experienced a non-injury fall in his/her unit. There was no documented evidence the facility determined and documented any actions or interventions were needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 09/01/23 a Hospice Provider Collaboration Note noted the resident self-reported a non-injury fall to the provider. The note was transcribed to the resident's clinical record. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 09/04/23 the resident experienced a fall in his/her unit, sustaining a laceration to the forehead. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 09/09/23 the resident experienced a fall in a common area of the facility, sustaining an abrasion to the right elbow. There was no documented evidence the facility determined and documented any actions or interventions needed related to the fall or communicated interventions to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 09/11/23 the resident experienced a non-injury fall in his/her unit. Staff reported the resident's oxygen saturation levels were 82% immediately after the fall. Hospice was notified and the resident received an order for PRN oxygen at two liters. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * During an 10/19/23 interview with Staff 2 (Health and Wellness Director) s/he stated the oxygen was an intervention for the resident's falls as they determined Resident 5's oxygen saturation levels were often low, effecting his mobility; * On 09/15/23 the facility scheduled daily housekeeping for Resident 5 as an intervention to aide in the prevention of falls; * On 09/25/23 the resident experienced a non-injury fall in his/her unit. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; * On 09/30/23 the resident experienced a non-injury fall in his/her bathroom after tripping over oxygen tubing. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift. The record lacked evidence the resident was monitored for the fall, with progress noted at least weekly, through resolution; and * On 10/06/23 the resident experienced a non-injury fall in the facility dining room. There was no documented evidence the facility evaluated previous fall interventions to determine if they were effective or if new interventions needed to be developed and communicated to staff on each shift. In an 10/19/23 interview with Staff 2 (Health and Wellness Director), she confirmed the facility lacked documented evidence each of the resident's falls were evaluated to determine if interventions were needed or if previously implemented interventions needed to be re-evaluated for effectiveness. Resident 5 was identified to be at risk for falls and experienced multiple non-injury and injury falls.  The facility failed to review each fall to determine what action or intervention was need to help minimize falls and/or failed to  determine if service planned interventions were in place and effective. Resident 5 continued to fall. b. Review of the records revealed Resident 5 also experienced the following short-term changes of condition: * 07/25/23 - Emergency room visit/shortness of breath; * 07/30/23 - Medication change, start lorazepam 0.5 mg give one tablet by mouth every six hours PRN; * 09/04/23 - Laceration to forehead; * 09/09/23 - Abrasion to right elbow; and * 09/11/23 - New order, start oxygen two liters PRN. There was no documentation the facility developed actions or interventions, communicated the actions or interventions to staff on each shift, and monitored each condition with progress noted at least weekly through resolution for Residents 5's medication and treatment orders and emergency room visit. The need to ensure the facility had a system to monitor each resident, determine and document what actions or interventions were needed for the resident's short term changes of condition, ensure actions or interventions were communicated to staff on each shift and documented, at least weekly, until the conditions resolved was discussed with Staff 1 (ED) and Staff 2 on 10/19/23. They acknowledged the findings. 4. Resident 3 was admitted to the facility in 07/2022 with diagnoses including Parkinson's disease. The resident's clinical record, including progress notes, temporary service plans, and incident reports were reviewed, and interviews were conducted. The following was identified: An 08/08/23 progress note entry stated, "Resident refused to go down to lunch today because [s/he] is upset that some other residents are being homophobic, or saying homophobic things...Will continue to monitor." There was no documented evidence this incident had been evaluated, actions or interventions had been determined and implemented, or interventions monitored for effectiveness. The need to evaluate, determine actions or interventions for, and monitor interventions for effectiveness was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 5. Resident 4 was admitted to the facility in 11/2015 with diagnoses including cervicalgia (neck pain) and heart failure. The resident's clinical record, including progress notes, temporary service plans, and incident reports were reviewed, and interviews were conducted. The following was identified: * 09/13/23 - A change in warfarin (for anticoagulation) dosage; * 09/26/23 - New medications, including ferrous sulfate (for supplement) and ascorbic acid (for supplement); * 09/26/23 - A change in hydrocodone-acetaminophen (for pain) from PRN medication to scheduled; and * 09/29/23 - A change in Lasix (for edema) dosage. There was no documented evidence these changes of condition had been monitored through resolution. The need for short-term changes of condition to be monitored through resolution, with progress documented at least weekly, was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 6. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe) and Type 2 diabetes mellitus with diabetic chronic kidney disease. Review of clinical records, including the service plan dated 10/03/23, progress notes from 07/17/23 through 10/15/23, and interviews with facility staff and the resident revealed the following: a. On 07/18/23 the resident was identified as having a left heel pressure ulcer, stage two. There was no documented evidence staff notified the facility nurse of the significant change of condition. b. The following short-term changes of condition lacked documentation the facility determined what resident-specific action or intervention was needed for the resident, communicated the determined action or intervention to staff, and documented weekly progress until the condition resolved: * 07/18/23 - Foley catheter changed; * 07/26/23 - Flu vaccination; * 07/28/23 - ER visit related to new onset of chest pain; * 07/31/23 - ER visit related to cramps and numbness in hands and legs and chest pain; * 07/31/23 - ER visit related to bleeding from Foley catheter site and pain 8/10; * 08/31/23 - Foley catheter changed; * 08/31/23 - '' 'Home Health/Hospice/Third Party Provider Collaboration Notes' ...Pt has sore in [right genital area] due to [Foley catheter] rubbing ..."; and * 09/29/23- " 'Home Health/Hospice/Third Party Provider Collaboration Notes' [Genital area] is very red and swollen, red rash in groin." The need to ensure the facility evaluated the resident, referred to the facility nurse, documented the change, and updated the service plan as needed for a significant change of condition, and determined what resident-specific action or intervention was needed for the resident following a short-term change of condition, communicated the determined action or intervention to staff, and documented progress until the condition resolved was discussed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. Resident #5 fall interventions for incidents listed in the Statement of Deficiency (SOD) were developed and communicated to staff then added to the care plan. Additional items listed in the SOD for Resident 5 including ER visit, medication changes, skin issues, and oxygen use were reviewed and appropriate interventions were communicated to staff and added to resident's care plan. Resident #1 was placed on monitoring on 10/16/23 related to missing medications and was monitored until medications were received on 10/20/23. Resident #6 was reviewed for medication changes and suicidal ideation. Interventions were developed as appropriate and added to resident's care plan. Resident #3 was reviewed for concerns regarding dining room and potentially homophobic speech that upset resident. Intervention developed and added to resident's care plan. Resident #4 was reviewed for medication changes and interventions were developed as needed and added to the care plan. Resident #2 was reviewed for hospital visits, skin issues, and catheter care. Interventions were developed and added to the care plan. 2. Daily at clinical meeting, resident changes, including but not limited to medication and skin changes, hospital/ER visits, fall interventions and behavioral changes will be reviewed and followed up on as appropriate. Community wil also complete a collaborative care review each month in which every resident will be reviewed by department head team. Medication Techs (MT), RCCs, and Health and Wellness Director were provided with training regarding TSPs, change of condition and monitoring, and staff log. All residents were reviewed for changes in condition and interventions were developed and added to care plans as needed. 3. Daily for any resident changes and monthly for all residents 4. Health and Wellness Director and Executive Director, or designee.

3. Resident 10 was admitted to the facility in 10/2023. Resident 10's clinical record and charting notes, reviewed from 12/18/23 through 01/29/24, revealed the following: On 12/23/23, staff reported the resident had a bed bug infestation. S/he was immediately relocated to another apartment until the infestation was resolved. The facility initiated short-term monitoring the same day. However, no monitoring until resolution was documented for the short-term change in condition. Additional information was requested on 01/31/24. On 01/31/24, Staff 1 (ED) reported she reviewed the resident's record and concluded the short-term change in condition had not been monitored until resolved. No further information was provided. The need to ensure the facility monitored short term changes of condition with weekly progress noted until resolution was reviewed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24 at 2:40 pm. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents with changes of condition were evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and the conditions were monitored through resolution for 3 of 4 sampled residents (#s 8, 9 and 10) who were reviewed with changes of condition. Resident 8 experienced a significant and ongoing decline in his/her ability to eat independently and had a severe weight loss. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. Review of clinical records, including the resident's evaluation and service plan dated 01/18/24, progress notes, observations of the resident, and interviews with staff and the resident revealed the following: The resident's evaluation dated 01/18/24 indicated the resident was on a regular diet with thin liquids, had natural dentition and reported no problem chewing. The resident was able to cut up his/her own food, had a history of malnutrition, and ate all meals in his/her apartment. Staff were to unwrap his/her meal tray and cue the resident to eat. If s/he did not eat at least 50% of the meal, staff were instructed to report to LN/RCC for additional monitoring as needed. The resident's service plan dated 01/18/24 directed staff to uncover and set-up meal trays and offer a "Mighty Shake" (nutritional supplement) with meals. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following information and instructions for nutrition and hydration for the facility: * 09/29/23 - "Patient with difficulty at times bringing food to mouth." * 09/30/23 - "Patient appears to be declining. Please keep an eye on patient for signs of decline and call hospice when needed." * 10/02/23 - "Increased swallowing difficulty, more frequent checks, especially during meals due to difficulty swallowing." * 10/06/23 - "Patient very drowsy, uneaten breakfast before them, began eating banana peel, patient appearing more thin. Patient is more thin in face and eating less." * 11/22/23 - "Patient unable to focus, uneaten lunch on the over the bed table. * 12/12/23 - "Patient unable to focus, unable to bring food to mouth. Assisted with one bite of food, patient took a long time to chew and swallow one bite." * 12/29/23 - "Patient's breakfast untouched and out of reach." * 01/23/24 - "Patient attempting to eat Jell-o, drizzled all down front, same with chocolate candy." * 01/24/24 - "Less alert/oriented." Observations of the resident at morning and noon meals between 01/29/24 through 01/30/24 showed the resident was bed bound, weak with decreased strength, and fluctuating levels of alertness. The resident demonstrated difficulty managing the utensil, scooping the food and bringing it to his/her mouth, and difficulty chewing and swallowing. The resident had difficulty grasping a water bottle and bringing it to his/her mouth to drink. The resident had dry, chapped lips and a dry oral cavity. The resident was observed to eat less than 50% of meals. Interviews with the resident, staff and Witness 1 (hospice RN) between 01/29/24 through 01/31/24, showed the following: * Resident 8 stated, "Softer foods might be nice...I could use some help with eating." * Staff 9, 23, 25, and 27 (MT/CGs) stated they did not provide one-to-one feeding assistance, staff did not provide a nutritional supplement drink and did not document or monitor Resident 8's meal intakes. * Witness 1 stated she spoke to Staff 1 (ED) and Staff 2 (Health and Wellness Director) on multiple occasions and requested the facility to provide one-to-one feeding assistance for Resident 8 and was informed the facility did not provide feeding assistance. On 01/30/24, the previous six months of weight records were requested and identified the following: * On 06/21/23, the initial move-in weight for Resident 8 was 72 pounds. The facility was unable to provide additional weight records. * On 01/31/24 at 2:20 pm, the surveyor requested a current weight for the resident. The surveyor observed Staff 29 (CG) obtain the resident's weight. The resident weighed 60 pounds, indicating a 12 pound weight loss, which constituted a 16.6% loss of body mass within six months. This constituted a severe weight loss. There was no documented evidence the facility evaluated and monitored Resident 8's ability to eat independently and consume adequate nutrition/hydration to determine resident-specific actions or interventions that were needed to prevent weight loss, communicated the actions or interventions to staff on each shift, and reviewed the interventions for effectiveness. This put the resident at risk for weight loss. On 01/30/24, two surveyors and Staff 28 (Regional RN) observed the resident at the noon meal. Staff 28 acknowledged the resident was unable to independently feed him/herself. Staff 28 stated she would develop interventions to ensure the resident received the assistance needed to ensure his/her nutritional needs were met. On 02/01/24, the facility provided a temporary service plan (TSP) with the following interventions and staff instructions: * Sit the resident upright in bed at a 90 degree angle; * Place a chair at the side of the bed facing the resident to assist the resident during the meal; * Allow the resident to feed herself when possible, engage the resident in conversation; * If it is necessary to assist the resident with eating, try cueing. If more assistance is needed, show the resident how to eat by demonstrating the hand over hand technique; * If complete assistance with eating is needed, offer small bites of food and offer fluids frequently and alternate food with a beverage; and * Do not rush the resident. Allow the resident adequate time to chew and swallow before introducing or assisting the resident with the next bite of food or drink of fluid. On 02/01/24 the need to ensure Resident 8's weight loss and ADL decline was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, documentation of staff instructions or interventions was resident specific and was made part of the resident record was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings. b. Review of the Assisted Living Open Area Flow Sheet dated 12/08/23, identified a left shin skin tear. The resident's December 2023 and January 2024 MARs and TARs did not reflect any hospice instructions for wound care treatment. There was no documented evidence the facility updated the resident's service plan with the hospice instructions or communicated the new instructions to staff. The facility failed to ensure Resident 8's skin tear was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, documentation of staff instructions or interventions was resident specific and made part of the resident record with weekly progress noted until the condition resolved. The skin tear, observed on 02/01/24 at 11:50 am with Staff 6 (RCC), revealed the left lower leg was bruised and the skin was scabbed. Staff 6 and the surveyor agreed the skin tear warranted further monitoring. The facility's failure to ensure Resident 8's skin tear was evaluated to determine what actions or interventions were needed, the actions or interventions were communicated to staff on each shift, and monitoring of the wound at least weekly through resolution was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings. 2. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease and Type 2 diabetes mellitus. The resident's clinical record, including progress notes, was reviewed, and interviews were conducted. The following change of conditions lacked documentation of resident specific actions or interventions needed for the resident, communication of the determined actions or interventions to staff on all shifts, and documentation of progress noted, at least weekly, through resolution: a. Review of "Open Area Flow Sheet" identified redness in the groin area with onset date 11/27/23. On 01/19/24, Staff 2 (Health and Wellness Director) noted the skin was intact, macerated and redness persists. Will continue to monitor weekly or until resolved. Review of the December 2023 MAR identified MT's were initialing the MAR for administration of barrier cream one time per day. Observation of the medication cart on 01/30/24 at 12:45 pm, identified there was no barrier cream in the medication cart. Staff 9 (MT) reported, "I think the caregivers are applying it." There was no documented evidence the facility provided written communication of the resident's skin issue and any required interventions, for caregivers on each shift and documentation the facility monitored the skin issue with progress noted at least weekly through resolution. b. Review of "Open Area Flow Sheet" identified a skin injury to the left side of the coccyx bone with onset date 12/26/23. On 01/19/24, Staff 2 noted wound measurements for the left side of coccyx were 1.7 x 1.1 x 0 cm, skin was pink and intact. No signs of infection, cleansed area and covered with Opi-foam. Will continue to monitor weekly or until resolved. There was no documented evidence the facility monitored the resident's left side of coccyx bone with progress noted at least weekly through resolution. c. Review of "Open Area Flow Sheet" identified a skin injury to the right side of the coccyx bone with onset date 12/26/23. During an interview and observation of the medication cart on 01/30/24, with Staff 9 (MT), reported "hospice does wound care. We do it if it comes off." Staff 9 was unable to explain the wound care that was needed if the bandage came off and was not able to locate any bandages or other wound care supplies in the medication cart for the resident. Review of the MAR for December 2023 and January 2024 provided no instructions for unlicensed staff to provide the wound care and there was no documented evidence the wound care instructions were added to the service plan and/or were communicated to staff. There was no documented evidence the facility provided written communication of the resident's skin issue and any required interventions for caregivers on each shift, and documentation the facility monitored the skin issue with progress noted at least weekly through resolution. The need to ensure resident specific actions or interventions were determined and documented, communicated to staff on each shift, and the conditions were monitored, consistent with the resident's evaluated needs, with progress noted, at least weekly, until resolved was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings. Refer to C 280, example 2b.

1. Resident 8's service plan was updated to reflect nutritional needs including feeding assistance, nutritional shakes, and coordination with hospice. Resident is on a nutritional monitoring plan which includes monitoring food intake, providing nutritional supplement shakes and weekly weights. The gathered information will be reviewed by Executive Director, Health and Wellness Director, and/or Designee regularly to monitor resident's progress. Interventions will be evaluated for effectiveness ongoing and updated as needed. Re-education was provided during the staff meeting on 2/1/2024 regarding resident's nutritional plan. Additional clarification regarding delivery of resident's nutritional supplement shakes was provided to Medication Technicians on 2/8/2024. Dining Services Coordinator is also provided a weekly Nutrition Tracker, which has updated details of resident's nutritional needs for her to share with dining staff. Resident 9's orders for wound treatment were updated on 1/31/24 to reflect current hospice orders. Additionally, a Temporary Service Plan was initiated to communicate these treatments to care staff. For Resident 10, chart note was completed recording date resident returned to his apartment, closing the monitoring for relocation. 2. Changes in condition including, but not limited to weight changes, changes in Activities of Daily Living, skin changes, will be discussed on weekdays at clinical meeting and communicated to staff via Temporary Service Plans. Alert Charting will be completed at least once per day by community staff and then closed by Executive Director, Health and Wellness Director, or designee. If temporary changes are significant or ongoing, an assessment will be completed by Health and Wellness Director or nurse designee and updated on resident's service plan as needed. 3. Temporary changes will be monitored on week days during clinical meeting, daily charting to be completed, and service plan changes to be made as necessitated by resident changes. 4. Executive Director, Health and Wellness Director, and/or Designee

2. Resident 5 was admitted to the facility in 01/2021 and had a with diagnosis of hypertensive heart failure. During a 10/18/23 interview, Staff 2 (Health and Wellness Director) reported  Resident 5 underwent heart surgery including placement of a pacemaker in 06/2023. According to Staff 2 the resident continued to experience a decline in health including weakness and began to require staff assistance with ADL's after the surgery. The resident was admitted to hospice on 07/09/23. This constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. During a 10/18/23 interview, Staff 2 (Health and Wellness Director) acknowledged an RN assessment had not been completed for Resident 5's hospice admission. The need for the facility RN to conduct an assessment when a resident experienced a significant change of condition, was reviewed with Staff 1 (ED) and Staff 2 on 10/19/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an RN assessment was completed and/or completed timely for 2 of 3 sampled residents (#s 2 and 5) who experienced a significant change of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2023 with diagnoses including chronic kidney failure stage 4 (severe) and type 2 diabetes mellitus with diabetic chronic kidney disease. A review of the resident's clinical record dated between 07/17/23 and 10/15/23 identified the following: a.  An after-visit summary from the outside provider group, dated 10/02/23, stated Resident 2 "had a left ureteroscopy, laser lithotripsy and stent placement. [Resident 2] also had a suprapubic tube placement today." The suprapubic tube placement constituted a significant change in condition requiring an RN assessment. There was no documented evidence the facility RN conducted an assessment which included documentation of findings, resident status, and interventions made as a result of the assessment. b. Home Health Third Party Provider Collaboration Notes dated 07/18/23 indicated the presence of a pressure ulcer stage II. The facility RN completed an assessment of the pressure ulcer on 07/26/23, 8 days after the wound was identified and was not timely. The need to ensure an RN assessment was completed and/or completed timely for residents who experienced a significant change of condition was reviewed with Staff 1 (ED) and Staff 2 (Health and Wellness Director) on 10/19/23. They acknowledged the findings. No further information was provided.

1. RN completed assessment for Resident 2 regarding change of condition related to suprapubic cathereter placement and on current skin deficits on 11/3/23. RN completed change of condition assessment for Resident 5 on 10/23/23 related to admission to hospice and care changes. 2. Resident health changes will be reviewed and discussed daily at clinical meeting.  All residents will be reviewed monthly by department head team at collaboritive care review. All residents reviewed for change of condition then nursing assessments and service plan updates were completed as needed 3. Daily for resident changes and monthly for all residents. 4. Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure an RN assessment was completed timely and documented findings, resident status, and interventions made as a result of the assessment for 2 of 2 sampled residents (#s 8 and 9) who experienced significant changes of condition. Resident 8 experienced a decline with ADLs and a severe weight loss. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. Observations of the resident, staff interviews, progress notes, and the 01/18/24 evaluation and service plan were reviewed during the survey. The evaluation and the service plan dated 01/18/24 identified the following: * The resident was on a regular diet with thin liquids; * The resident had natural dentition and had no problems chewing; * The resident was able to cut up his/her own food; * Ate all meals in his/her apartment; * Staff were to unwrap his/her meal tray and cue the resident to eat; * If the resident did not eat at least 50% of his/her meal, staff were instructed to report to LN/RCC for additional monitoring as needed; and * Staff to offer the resident a "Mighty Shake" (nutritional supplement) with meals. Observations of the resident 01/29/24 through 01/30/24 morning and noon meals identified the following: * The resident was bed bound, weak with decreased strength, and fluctuating levels of alertness; * Demonstrated difficulty managing the utensil, scooping the food, difficulty grasping his/her water bottle and bringing it to his/her mouth to eat and drink; * Difficulty chewing and swallowing; * The resident had dry, chapped lips and a dry oral cavity; * The resident was observed to eat less than 50% of meals; and * There was no nutritional supplement provided to the resident. Interviews with the resident, staff and Witness 1 (hospice RN) on 01/29/24 through 01/31/24, showed the following: * Resident 8 stated, "Softer foods might be nice...I could use some help with eating." * Staff 9, 23, 25, and 27 (MT/CGs) stated they did not provide one-to-one feeding assistance, did not provide the resident with a nutritional supplement and did not document or report Resident 8's meal intakes. * Witness 1 stated she spoke to Staff 1 (ED) and Staff 2 (Health and Wellness Director) on multiple occasions and requested the facility to provide one-to-one feeding assistance for Resident 8 and was informed the facility did not provide feeding assistance. On 01/30/24, the previous six months of weight records were requested and identified the following: * On 06/21/23, the initial move-in weight for Resident 8 was 72 pounds. The facility was unable to provide additional weight records. * On 01/31/24 at 2:20 pm, the surveyor requested a current weight for the resident. The surveyor observed Staff 29 (CG) weigh the resident. The resident's weight at that time was 60 pounds, indicating a 12-pound weight loss, which constituted a 16.6% loss of body mass within six months. This constituted a severe weight loss. The resident's decline in ADLs to eat independently and maintain adequate nutrition and hydration, constituted a significant change of condition, requiring an RN assessment. There was no documented evidence the RN completed an assessment of the resident's ADL decline, which documented findings, resident status, and interventions made as a result of the assessment. This put the resident at risk for severe weight loss. On 01/30/24, two surveyors and Staff 28 (Regional RN) observed the resident at the noon meal. Staff 28 acknowledged the resident was unable to independently feed him/herself. Staff 28 stated she would develop interventions to ensure the resident received the assistance needed to ensure his/her nutritional needs were met. The facility's failure to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment for Resident 8's ADL decline in his/her ability to eat independently and the severe weight loss was discussed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings. Refer to C 270 example 1a, C 290 example 1b. 2. Resident 9 moved into the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus. During the acuity interview it was reported the resident recently had a rapid decline in ADL ability and had admitted to hospice. Review of the resident's clinical record, including charting notes and current evaluation and service plan dated 01/12/24 identified the following: a. The resident had a significant decline in ADL ability and admission to hospice on 01/12/24. This constituted a significant change of condition that required an RN assessment. There was no documented evidence of an RN assessment which documented findings, resident status and condition, and any interventions needed as a result of the assessment. b. The resident had multiple chronic reoccurring pressure wounds on the left and right side of coccyx bone with onset date 12/26/23. Review of the MAR for December 2023 and January 2024 provided no instructions for unlicensed staff to provide the wound care and there was no documented evidence the wound care instructions were communicated to staff. During an interview on 01/29/24, Witness 3 (hospice RN)  reported the resident had Stage 2 wounds on his/her buttocks area and upper leg area near the skin folds where his/her upper leg and buttock joined. During an interview on 01/29/24 with Staff 1 (ED) and Staff 2 (Health and Wellness Director), it was reported s/he doesn't have any open wounds. Staff 1 stated "there is discrepancies in the documentation from HH and what hospice is reporting to us." Staff 1 requested Staff 2 "take a look at it and report back to her." On 01/29/24 at 3:30 pm, Staff 2 reported "There is no open area on [his/her] thighs. I didn't look at the coccyx, or that area, I didn't remove[his/her] brief." Upon review of the resident's clinical record there was no documented evidence the RN completed an assessment of the wounds which documented findings, resident status and condition and any interventions needed as a result of the assessment, and there was no update to the service plan to include the above wound care instructions. At the request of the survey team, the RN surveyor and Staff 28 (Regional RN) made observations of the resident's coccyx, buttocks, left and right posterior upper thigh area. Staff 28 completed a skin assessment and determined the resident's skin status required continued skin monitoring. Staff 28 also initiated the following skin care interventions: repositioning three to four times per shift, hospice will provide a new order for zinc oxide, an air alternating mattress and a new hospital bed. The need to ensure the RN completed an assessment which documented findings, resident status, and interventions made as a result of the assessment for all significant changes of condition was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Significant change in condition assessment was completed on 1/31/24 for Resident 8 in regards to her ability to feed herself. Changes and instructions for staff were communicated via a Temporary Service Plan.  Service plan was updated with resident's current needs and staff instruction. Significant change in condition assessment was completed on 1/31/24 for Resident 9 on regarding her skin condition and catheter. Changes and instructions for staff were communicated via Temporary Service Plan and nursing orders updated in the Medication Administration Record. Service plan was updated to reflect the resident's current needs and staff instruction. 2. When a change of condition is identified, Heath and Wellness Director or nurse designee will complete a nursing assessment. Any staff instruction or ongoing monitoring needs will be communicated to staff with Temporary Service Plans, on the Medication Administration Record, and with Service Plan updates as needed. Executive Director will review a significant change in condition with Health and Wellness Director to verify each step is completed. 3. The assessment will be completed with each significant change in condition as needed. 4. Executive Director, Health and Wellness Director, and/or Designee

2. Resident 5 was admitted to the facility in 01/2021 and was admitted to hospice in 07/2023. The resident's 07/16/23 through 10/16/23 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, Temporary Service Plans (TSP's) and 08/01/23 service plan were reviewed. The records indicated Resident 5 received hospice services from an outside provider for concerns including hypertensive heart failure. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following instructions for the facility: * 09/11/23 - "Staff to offer stand by assist with ambulation ...continue to keep head of bed elevated"; and * 10/07/23 - "Encourage patient to wear oxygen." There was no documented evidence the facility updated the resident's service plan with those instructions or communicated the new instructions to staff. The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided for 2 of 3 sampled residents (#s 4 and 5) who received on-site health services. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 06/2023 with diagnoses including history of falling and congestive heart failure. The "Home Health/Hospice/Third Party Provider Collaboration Notes," dated 07/12/23 through 08/30/23, were reviewed and revealed the following recommendations: * 08/08/23 - "Please encourage activity engagement of walking with assist."; * 08/09/23 - "Order has been send for stool collection to be placed on ice. Please call...if stool is collected."; * 08/18/23 - "Please ask [him/her] about pain before bed."; * 08/23/23 - "Please check [resident's] pain level every shift. Fax to follow."; * 08/30/23 - "Assist patient with Dermafit [compression stockings]. Don in am, off in pm. Should have order to check pain level." Resident 4 was observed without Dermafit donned throughout the morning and daytime hours on 10/17/23 and 10/19/23. There was no documented evidence the facility updated the resident's service plan as necessary after being informed of the new interventions. The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. By 11/15/23, recomendations from Outside Providers reviewed for Resident #4 and #5 and commuicated to staff via TSPs and eMAR as needed. 2. Outside provider notes will be reviewed at daily clinical meeting and updates will be made to resident records as appropriate. Outside Provider notes for the last 30 days were reviewed and interventions developed as needed. 3)  Daily at clinical meeting. 4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview, and record review, it was determined the facility failed to coordinate on-site health services with outside service providers to ensure staff were informed of new interventions and the service plan was adjusted as necessary for 2 of 2 sampled residents (#s 8 and 9) who received outside services. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved  into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. During the acuity interview, staff reported the resident received hospice services. Observations of the resident, the resident's 12/08/23 through 01/24/24 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, and 01/18/24 service plan were reviewed. The records indicated Resident 8 received hospice services for concerns including difficulty swallowing and wound care. a. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following wound care instructions for the facility: * 12/08/23 - "The patient has a wound on his/her left shin. Hospice orders included: cleanse with wound cleanser, pat dry with gauze, apply skin prep, spray or wipe to intact skin surrounding the wound, cover with bandaid bordered gauze, change every seven days or PRN soilage or coming off, ok to discontinue once area is healed." * 12/30/23 - "The bandage on the resident's left shin was removed to be open to air and to keep the resident clean, dry and apply barrier cream." There was no documented evidence the facility updated the resident's service plan or December 2023 MAR with the hospice instructions or communicated the new instructions to staff. b. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated hospice providers left the following information regarding nutrition and hydration for the facility: * 12/12/23 - "Patient unable to focus, unable to bring food to mouth. Assisted with one bite of food, patient took a long time to chew and swallow one bite." * 12/29/23 - "Patient's breakfast untouched and out of reach." * 01/23/24 - "Patient attempting to eat Jell-o, drizzled all down front, same with chocolate candy." * 01/24/24 - "Less alert/oriented." In an interview on 02/01/24 at 11:05 am, Staff 1 (ED) stated there was no facility follow-up on the information from hospice's notes. There was no documented evidence the facility nurse reviewed the above outside service provider notes that were left in the facility and adjusted the resident's services and service plan, as applicable. The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings. 2. Resident 9 moved into the facility in 03/2017 with diagnosis including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus. During the acuity interview it was reported the resident was receiving home health services and recently admitted to hospice. The resident's 12/18/23 through 01/29/24 "Home Health/Hospice/Third Party Provider Collaboration Notes", progress notes, Temporary Service Plans (TSP's) and 01/12/24 service plan were reviewed. Review of the "Home Health/Hospice/Third Party Provider Collaboration Notes" indicated home health providers left the following instructions for the facility: * 12/22/23 - home health recommendation: manual wheelchair needs to be replaced for a larger wheelchair due to the wheelchair causing skin injury; * 12/22/23 - home health recommendation: Assess patients pain every four hours; * 01/09/24 - home health recommendation: Delegation to MT to change posterior right thigh wound dressing and coccyx wound dressing every Tuesday and PRN to keep wounds covered until healed. On 01/30/24 at 12:16 pm the surveyor observed the resident's wheelchair had not been replaced and the resident confirmed s/he had not received a new wheelchair. On 02/01/24 at 9:45 am the surveyor and Staff 9 (MT) observed wound care supplies were not in the medication cart. There was no documented evidence the facility updated the January MAR or updated the resident's service plan with those instructions or communicated the new instructions to staff. The need to ensure staff were informed of new interventions and the service plan was updated after on-site health services were provided was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. For Resident 8, a skin assessment was completed by the nurse on 1/31/24 to identify any current skin issues and to coordinate with hospice regarding reccomendations for wound care as needed. Additionally, a nutritional plan was developed in collaboration with hospice to include feeding assistance, food intake monitoring, nutritional shakes, and weekly weight monitoring. Third Party Notes for January and February 2024 will be reviewed by 3/17/24 to verify that recommendations were appropriately communicated to staff via Temporary Service Plan.  The Executive Director or Health and Wellness Director or designee, will follow up to verify that these recommendations were implemented along with their effectiveness. For Resident 9, the Executive Director coordinated with hospice regarding resident's wheelchair.  A progress note was completed, and instructions for staff were communicated via a Temporary Service Plan. Skin assessment was completed for Resident 9 on 1/31/24 by RN to identify current skin concerns and coordinate with hospice regarding necessary wound care. Wound care orders were communicated to staff via Temporary Service Plan and in the Medication Administration Record. 2. Executive Director or designee will review each third party collaboration note and provide to Health and Wellness Director any which note changes in the resident's condition. The Executive Director, Health and Wellness Director, and/or designee will complete Temporary Service Plans, update Medication Administration Record, and document skin changes as needed based on third party coordination. 3. Notes will be reviewed Monday through Friday at clinical meeting with updates and assessments completed as needed. 4. Executive Director, Health and Wellness Director, and/or Designee.

Based on interview and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed and ensure written, signed physician orders were documented in the resident's facility record for all medications the facility was responsible to administer for 4 of 6 sampled residents (#s 3, 4, 5, and 6) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including depression and high blood pressure. Physician's orders and MARs dated 09/01/23 through 10/16/23 were reviewed. The following medications were identified as not being available to staff for administration: * Citalopram (for major depression), 10 mg once daily, was not available from 09/22/23 through 09/30/23; * Docusate (for constipation), 100 mg once daily, was not available on 09/22/23, from 09/27/23 through 09/29/23, and from 10/01/23 through 10/08/23; * Lisinopril (for high blood pressure), 20 mg once daily, was not available on 09/23/23; and * Loratadine (for allergies), 10 mg once daily, was not available from 09/21/23 through 10/12/23. On 10/19/23 at 11:14 am, Staff 1 (ED) confirmed the facility purchased docusate and loratadine for Resident 6, and s/he was recently enrolled in a monthly auto-fill program with the resident's pharmacy for physician-ordered medications. The need to ensure medication orders were carried out as prescribed was discussed with Staff 1, Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 4. Resident 5 was admitted to the facility 01/2021 with diagnoses including Type 2 diabetes and heart disease. The resident's MARs, dated 09/01/23 through 10/16/23, and physician's orders were reviewed. The following were identified: Resident 5 had a physician order to administer metoprolol succinate (for hypertension) 50 mg once daily. Hold for systolic blood pressure (SBP) less than or equal to 110 and hold for heart rate less than or equal to 60. a. The MARs showed Resident 5 was administered the medications when the resident's SBP was within the "hold" parameters and should have been held, as follows; * 09/01/23 - SBP reading was 103, metoprolol was administered; and * 09/11/23 - SBP reading was 103, metoprolol was administered. b. Resident 5's Humalog orders (insulin) directed the facility to notify the RN and the physician when the residents's blood sugar level exceeded 350. The resident's blood sugars levels exceeded 350 on 09/01/23, 09/02/23, 09/16/23, 09/20/23, 09/22/23, 09/24/23, 09/27/23, 09/29/23, and 09/30/23. There was no documented evidence the RN and physician were notified as ordered. c. Resident 5's physician order, dated 09/15/23, directed staff to "add oxygen to the plan of care at [two liters], PRN for saturations below 88%." In an interview with Staff 2 (Health and Wellness Director) on 10/18/23, she acknowledged the order was received but not updated on the MARs. The need to ensure physician's orders were carried out as prescribed was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including hypertension and orthostatic hypotension. Resident 3's MARs, dated 09/01/23 through 10/16/23, and corresponding progress notes and prescriber orders were reviewed and revealed the following: The resident had an order for Midodrine HCl 5 mg (for orthostatic hypotension) to be administered one tablet three times daily. If blood pressure was greater than 135/60, order stated to hold medication dose one time a day. * Midodrine HCl was held on 12 occasions in September and on two occasions in October when orders were to administer; and * Midodrine HCl was administered on three dates in September when blood pressure was greater than 135/60 and no medication dose was held on those dates. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings, 3. Resident 4 was admitted to the facility in 06/2023 with diagnoses including anemia and cervicalgia (neck pain). Resident 4's MARs, dated 09/01/23 through 10/16/23, corresponding progress notes and physician's orders were reviewed and revealed there was no documented evidence the facility had physician's orders to administer the following medications: * Ascorbic acid tablet (for supplement), 250 mg, one tablet, once daily; * Ferrous sulfate tablet (for supplement), 325 mg, one tablet, once daily; and * Hydrocodone (for pain), 5-325 mg, one tablet, four times daily. The need to ensure signed physician or other legally recognized practitioner orders for all medications were in the resident's facility record was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings, and no additional documentation was provided.

1. For Resident #6 medications listed in SOD were ordered or purchased. For Resident #3 order was clarified from provider to hold Midodrine for blood pressure greater than 135/60 each time the medication is given. For Resident #4 signed orders were obtained for medications listed in SOD. For Resident #5, MTs were provided with training regarding nursing notifications and oxygen order was update in the MARs. 2. Health and Wellness Director (HWD) or designee will review missed medications during clinical meeting and assist in reordering medications as needed. Medication carts will be audited monthly to review supplies on hand. Medications for individual residents will be reviewed quarterly during service planning again to reconcile supplies with physician orders. MTs received training regarding medication ordering, when to notify the HWD, and order entry. All resident's were reviewed too ensure signed orders and all medications were on hand 3. Daily during clinical meeting, monthly during cart audits, and quarterly during service planning. 4. Health and Wellness Director and Executive Director or designee

Based on observation, interview, and record review, it was determined the facility failed to carry out medication and treatment orders as prescribed for 2 of 3 sampled residents (#s 8 and 9) whose orders were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. Review of Resident 8's physician orders dated 01/12/24 and MARs from 12/18/23 through 01/29/24 revealed the following: Resident 8's physician's order dated 06/21/23 which directed staff to provide a nutritional supplement drink, such as Boost or similar product, three times a day with every meal. Observations of the resident during the morning and noon meals on 01/29/24 through 01/31/24 revealed Resident 8 did not receive the physician ordered nutritional supplement drink despite staff signed as provided on the resident's MARs. Interviews conducted with staff on 01/29/24 through 01/30/24 between 10:20 am - 4:10 pm revealed the following: Staff 13 (MT), Staff 24 (Dining Services Manager), Staff 23, 25 and 27 (CGs), stated they were unaware Resident 8 had an order to receive a nutritional supplement drink with each meal. The need to ensure physician orders were carried out as prescribed was reviewed with Staff 1 (ED) and Staff 6 (RCC) on 02/01/24. They acknowledged the findings. 2. Resident 9 moved into the facility in 03/2017 with diagnoses including Type 2 diabetes mellitus. Resident 9's MARs, dated 12/18/23 through 01/29/24 and prescriber orders were reviewed and identified the following: a. The resident had an order for Lantus SoloStar insulin (for diabetes) to inject 33 units in the morning. Hold for CBG under 150. * On 12/18/23 the residents CBG was 120;   * On 12/25/23 the residents CBG was 131; and * On 01/01/24 the residents CBG was 200. There was no documented evidence the insulin was held on 12/18/23 or 12/25/23 and on 01/01/24 the MAR indicated the insulin was held when it should have been administered. b. The resident had an order for sliding scale Insulin Lispro (for diabetes), CBG's 141-180 administer 2 units. On 12/17/23 the residents CBG was recorded as 144. The MAR noted the MT held the insulin when they should have administered 2 units. The need to ensure medications were carried out as prescribed was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Re-education was provided on 2/1/24 for unlicensed staff and on 2/8/24 for Medication Technicians regarding Resident 8's Nutritional Shake. Re-education for Medication Technicians regarding parameters for holding medications, and notification to the resident's physician has been scheduled for 3/6/24. Resident 9's insulin was discontinued so no further invention needed for that medication. Full review of Medication Administration Records for parameters, notifications, and clarification for unlicensed staff will be completed for the other residents by 3/17/24. 2. Medications held for outside parameters will be reviewed as part of clinical meeting daily to verify the parameters were followed and notifications made as needed. 3. Daily at clinical meeting. 4. Health and Wellness Director, Executive Director, or Designee

Based on interview and record review, it was determined the facility failed to notify the physician or other practitioner when a resident refused consent to orders for 1 of 1 sampled resident (# 1), who had documented medication and treatment refusals. Findings include, but are not limited to: Resident 4 was admitted to the facility in 06/2023 with diagnoses including cervicalgia (neck pain), constipation, and heart failure. The resident's MARs, dated 09/01/23 through 10/16/23, were reviewed and revealed facility staff documented Resident 4 refused the following orders: * Acetaminophen (for pain) on three occasions; * Metamucil (for constipation) on 15 occasions; and * Daily weights on six occasions. On 10/18/23, Staff 2 (Health and Wellness Director) confirmed there was no documented evidence the practitioner was notified of the multiple medication and treatment refusals. On 10/19/23, the need to notify the physician or other practitioner when a resident refused consent to orders was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC).  They acknowledged the findings, and no additional documentation was provided.

1. Resident #4's provider was notified of medication refusals. 2. Daily at clinical meeting all medication refusals and notifications will be reviewed for completion.  Any missed notifications will be completed at this time. Medication refusals  and notifications were reviewed for October 2023 for all residents to ensure physican was notified. 3. Daily at clinical meeting. 4. Health and Wellness Director and Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to ensure resident MARs were accurate and included resident specific parameters and instructions for PRN medications, for 3 of 5 sampled residents (#s 3, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 6 was admitted to the facility in 06/2023 with diagnoses including depression and high blood pressure. Physician's orders, MARs dated 09/01/23 through 10/16/23 and progress notes dated 07/17/23 through 10/14/23 were reviewed. The following inaccuracies were found: a. The parameters for administering lisinopril (for high blood pressure) were to notify the RN if "systolic [blood pressure] is above 160 or less than 90; if diastolic [blood pressure] is above 100 or less than 50; pulse is above 100 or less than 60." There were 31 times from 09/01/23 through 10/16/23 that the blood pressures or pulse rate was outside of the parameters. There was no documented evidence the RN was notified. b. Staff were directed to monitor for "significant side effects" related to an anti-depressant and lists the side effects of dizziness, nausea, diarrhea, anxiety, nervousness, insomnia, somnolence, weight gain, anorexia, and decreased appetite. The RN directed staff on each shift to "Document (+) if present and notify MD; (-) if not present." Staff documented "(+)" on 09/12/23, 10/08/23, and 10/14/23. There was no documented evidence the facility contacted the physician on the three dates. Additionally, staff were documenting "NA", "X", "0", "n", "N", and "y" instead of "(+)" or "(-)" as directed, 58 times between 09/01/23 through 10/16/23. d. Staff were directed to monitor the resident for depression on each shift, they were directed to "Document number of times behavior occurs", and "if present attempt non-pharmacological interventions: A - calm approach, B - therapeutic communication, C - decrease stimulation, D - see behavior note." Lastly, staff were to document "E-effective, I-ineffective". There were 42 instances between 09/01/23 and 10/16/23 when staff entered information that was not accurate based on the MAR instruction. The need to ensure residents' MARs were accurate was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 3. Resident 5 was admitted to the facility 01/2021 with diagnoses including Type 2 diabetes and heart disease. The resident's MAR, dated 09/01/23 through 10/16/23, and physician's orders were reviewed. The following inaccuracies were identified: * Resident 5's physician order for hyoscyamine (for secretions) 0.125 mg tablet directed staff to give every four hours; * Resident 5's MARs for hyoscyamine 0.125 mg tablet directed staff to give one tablet every four hours PRN; * Resident 5's physician order for haloperidol lactate (for agitation) 2 mg directed staff to give every six hours PRN; and * Resident 5's MARs did not reflect the order for haloperidol lactate 2 mg PRN. In an interview with Staff 2 (Health and Wellness Director) on 10/18/23, she acknowledged the order for haloperidol lactate was discontinued by the physician and the MARs were not updated. The need to ensure the MARs were accurate was discussed with Staff 1 (ED), Staff 2, and Staff 6 (RCC) on 10/19/23. They acknowledged the findings. 2. Resident 3 was admitted to the facility in 07/2022 with diagnoses including constipation. The resident's 09/01/23 through 10/16/23 MARs and physician's orders were reviewed. The following PRN bowel medications lacked resident specific parameters or instructions to direct non-licensed staff on which medication should be administered and in what order: * Fleet enema; * Milk of magnesia; and * MiraLax powder. During an interview on 10/18/23, Staff 9 (MT/Caregiver) confirmed the electronic MAR system did not have parameters on which medication should be administered and in what order listed for staff. The need to ensure resident's MAR was accurate and included resident specific parameters and instructions for PRN medications was reviewed with Staff 1 (ED), Staff 2 (Health and Wellness Director), and Staff 6 (RCC).  They acknowledged the findings.

1. Training provided to all Med Techs in regards to Resident #6 hold parameters and notifications to the RN. RN clarified parameters for bowel care meds for Resident #3. Resident #5's MAR updated to reflect current physician orders. 2. Daily at clinical meeting, MAR documentation as well as new physican orders will be reviewed to ensure MAR accuracy. During quarterly service planning, medication lists will be reviewed for medication parameters and then sent to physician for review. When resident's receives new or updated medication orders they will be monitored for potential adverse side effects and any ongoing interventions related to medications will be added to the care plan. 3. Daily at clinical meeting. 4. Health and Wellness Director and Executive Director or designee

3. Resident 10 was admitted in 10/2023 with diagnoses which included hypertension and diabetes. Residents 10's MARs and physician orders were reviewed from 01/01/24 through 01/29/24 and the following was noted: * The physician discontinued an order for Benadryl 25mg one tablet every six hours as needed for rash on 11/21/23. However, the discontinued medication was still listed on the current MAR; and * Resident 10's MAR instructed staff to administer Milk of Magnesia 30 ml as needed for bowel care "if Miralax is ineffective". However, neither the MAR nor record had an order for Miralax. In an interview on 01/31/24 at 3:15 pm, Staff 1 (ED) reviewed the resident's MAR and acknowledged it was inaccurate. She stated the MAR would be updated to reflect current, accurate orders. On 02/01/24 at 2:40 pm, the need to ensure MARs were accurate was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident-specific parameters for PRN medications for 3 of 3 sampled residents (#s 8, 9, and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to: 1. Resident 8 moved into the facility in 06/2023 with diagnoses including failure to thrive and severe protein-calorie malnutrition. a. Resident 8's MARs and physician orders were reviewed from 01/01/24 through 01/31/24 and found to be lacking resident-specific parameters and instructions for the following medications: * The MAR included multiple PRN pain medications that lacked clear parameters related to what sequence they should be administered and the MAR did not contain resident specific instructions for staff describing how the resident expressed pain. * The MAR included multiple PRN psychotropic medications for anxiety, agitation, and delirium. The MAR did not contain resident specific instructions for staff describing how the resident expressed anxiety, agitation, and delirium. b. From 01/01/24 through 01/30/24 MT's initialed that they administered a nutritional supplement three times per day. However, interviews with Staff 9 (MT) and Staff 13 (MT) revealed staff had not consistently administered the supplement and the MAR was inaccurate. On 02/01/24, the need for an accurate MAR including resident-specific parameters and clear instruction for unlicensed staff was discussed with Staff 1 (ED) and Staff 6 (RCC). They acknowledged the findings. 2. Resident 9 moved into the facility in 03/2017 with diagnoses including Type 2 diabetes mellitus. The resident's MAR, dated 12/18/23 through 01/29/24, and physician's orders were reviewed. a. The MAR documented the following inaccuracies related to the residents diabetic management: * CBG checks four times per day lacked medication specific instructions for when to notify the provider; * On 12/21/23 CBG value was marked out of parameter however, the CBG value wasn't recorded; and * On 12/30/23 and 12/31/23 sliding scale insulin lispro (for diabetes) was given without documenting the number of units administered.   b. The MAR lacked the following related to PRN psychotropic medications: An order for lorazepam every two hours, PRN for anxiety/agitation lacked clear medication instructions that directed unlicensed staff what anxiety/agitation looked like for the resident and when to notify the prescriber or nurse. c. Parameters and clear instructions for the following PRN pain medications: * Apply warm compress every 6 hours, PRN; * Tylenol every 4 hours, PRN; * Hydrocodone every 8 hours, PRN; * Instructions for how long to wait before administering hydrocodone after morphine was already administered; and * Monitor pain every two hours for three days. If asleep do not wake, mark as 02 code (defined on the MAR as med refused) if the resident was asleep. The need to ensure the MARs were accurate was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Re-education was completed with Medication Technicians on 2/8/24 regarding administration of items on the electronic Medication Administration Record. Re-education for Medication Technicians has been scheduled for 3/6/24 on medication administration process and parameters. Resident #8's MAR was updated to reflect instruction for staff regarding the specific instructions describing how to identify pain, anxiety, agitation, and delirium as well instructions on which  of resident's pain medications to administer first. Re-education provided on 2/8/24 regarding administration of resident 8's nutritional shake. Re-Education provided has been scheduled for Medication Technicians regarding sliding scale insulin and accurate recording of administered doses. Resident 9's MAR was updated to reflect instructions for unlicensed staff regarding resident's pain medications and how to identify anxiety/agitation. Resident #9's CBGs has been discontinued, so no further intervention needed. Resident 10 had new signed orders on 1/31/24 and MAR was updated to reflecty these orders. 2. At the clinical meeting, select Medication Administration Records and new physican orders will be reviewed to confirm their accuracy. Medication orders with hold parameters will be periodically reviewed.  The vitals log for residents with monitored vitals will be sent to their health care provider as needed. Resident orders and medication records will be reviewed by 3/17/24 to verify parameters are present and that notifications are being made to appropriate health care providers. 3. Daily at clinical meeting and additionally as needed. 4. Health and Wellness Director and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 1 sampled resident (#5) who was prescribed psychotropic medications. Findings include, but are not limited to: Resident 5 was admitted to the facility in 01/2021 with diagnoses including depression and anxiety. Review of Resident 5's MAR, dated 09/01/23 through 10/16/23, and physician orders revealed the following: * Clonazepam 0.5 mg (anti-anxiety medication), one tablet every six hours, PRN for anxiety; and * Lorazepam 0.5 mg (anti-anxiety medication), one tablet every six hours PRN for severe agitation. The above PRN psychotropic medications were administered to the resident five times from 10/01/23 through 10/16/23. There was no documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications. In an interview on 10/19/23, Staff 12 (MT) confirmed she was unaware of the non-pharmacological interventions to attempt for Resident 5.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                On 10/19/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED), Staff 2 (Health and Wellness Director) and Staff 6 (RCC) on 10/19/23. They acknowledged the findings.

1. Non-pharmacological interventions were developed and communicated to the staff related to Resident #5's as needed psychotropic. 2. Non-pharmacological interventions for new psychotropic medications will be developed when new orders are received. Exisiting interventions will be assessed for ongoing effectiveness during service planning. All residents with antipsychotic and benzodiazipine medications were reviewed and non-pharmacological interventions were put in place. 3. Will be evaluated daily during clinical meeting as needed with new psychotropic medication orders received. Interventions to be reviewed quarterly during service planning. 4.  Health and Wellness Director and ED

Based on interview and record review, it was determined the facility failed to implement an acuity-based staffing tool (ABST) which met the regulation. Findings include, but are not limited to: The facility's ABST was reviewed and discussed with Staff 1 (ED) on 10/18/23 at 11:30 am. Staff 1 reported the ABST was populated by the Resident Assessment, which was driven by the service plan for each resident. Three of six sampled resident service plans were not reflective of the resident status which would impact the ABST. There was no documented evidence all 22 of the required ADLs were addressed in the tool the facility was using. Additionally, the staffing hours recommended by the current tool were reviewed and failed to correspond with the number of staff listed on the staffing plan. The need to have all required ADLs on the ABST, and to ensure service plans were reflective so the ABST would be accurate, was discussed with Staff 1 on 10/19/23. She acknowledged the findings. No further information was provided.

1. Community is in process of working with Corrective Action on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. 2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool. 3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. 4. Executive Director or designee.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation. During an interview on 01/30/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST". A review of the facility's Acuity Based Staffing Tool (ABST) identified the following: 1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task. 2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming. 3. The tool failed to address the following ADL's, individually: * Personal hygiene; * Transfer in and out of bed or a chair; * Repositioning in bed or chair; * Assisting with leisure activities; * Assisting with communication, assistive devices for hearing, vision, speech; * Responding to call lights; and * Safety checks, fall preventions. The ABST tool was reviewed and discussed with Staff 1 on 01/30/24. She acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. 2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool. 3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. 4. Executive Director or designee.

Based on interview and record review it was determined the facility failed to fully implement an Acuity Based Staffing Tool (ABST) that met the regulation. This is a repeat citation. Findings include, but are not limited to: The facility previously had a condition placed on the facility's license because the ABST the facility was using didn't meet regulation. During an interview on 05/29/24, Staff 1 (ED) stated the facility was using the "Brookdale ABST". A review of the facility's Acuity Based Staffing Tool (ABST) identified the following: 1. The ABST tool failed to include all 22 activities of daily living (ADL's) outlined individually for each resident and an amount of staff time needed to provide each task. 2. The ABST had multiple ADLs grouped together in subcategories. For example, dressing was grouped together with grooming. 3. The tool failed to address the following ADL's, individually: * Personal hygiene; * Transfer in and out of bed or a chair; * Repositioning in bed or chair; * Assisting with leisure activities; * Assisting with communication, assistive devices for hearing, vision, speech; * Responding to call lights; and * Safety checks, fall preventions. The ABST tool was reviewed and discussed with Staff 1 on 05/29/24. She acknowledged the findings.

1. Community is in process of working with Corrective Action Team on reviewing Brookdale's Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. 2. As we work through our Acuity Based Staffing Tool (ABST)with the department, we will continue to staff using Brookdale's tool. 3. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. 4. Executive Director or designee

Based on interview and record review, it was determined the facility failed to ensure  unannounced fire drills included all required components. Findings include, but are not limited to: Facility fire drill records dated 04/2023 through 10/2023 were reviewed with Staff 4 (Maintenance Director) on 10/16/23. The facility lacked documented evidence unannounced fire drills included the following component: Problems encountered, comments relating to residents who resisted or failed to participate in the fire drills. The requirement to ensure unannounced fire drills included all required components was discussed with Staff 1 (ED) and Staff 4 on 10/19/23. They acknowledged the findings.

1. Drill was completed on 10/27/23 to include information on resident participation and concerns. 2. Monthly fire drills will include any problems encountered with or comments relating to residents who resisted or failed to participate in the fire drills. 3. Reviewed monthly during fire drills 4. Maintenance Manager and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed in fire and life safety procedures at least annually. Findings include, but are not limited to: On 10/16/23 fire and life safety records were reviewed with Staff 4 (Maintenance Director) and the following was identified: There was no documented evidence residents were re-educated annually in general fire and life safety procedures, evacuation methods, responsibilities and designated meeting places inside or outside the building in the event of an actual fire. On 10/19/23, the need to ensure fire and life safety instruction was provided to each resident at least annually as required by the Oregon Fire Code was discussed with Staff 1 (ED) and Staff 4. They acknowledged the findings.

1. All residents provided with fire and evacuation safety training with siganature obtaind to confirm training was completed. 2. Residents will be provided with fire and evacuation safety training annually by the Maintenance Manager or as part of a care conference. 3. At least once annually. 4. Maintenance Manager and Executive Director or designee.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training at least annually. This is a repeat citation. Findings include, but are not limited to: Fire and life safety records were requested and reviewed during the revisit survey. The following was lacking from the records: * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training at least annually was reviewed with Staff 1 (ED) on 01/31/24 at 10:20 am. The findings were acknowledged. No further information was provided.

1. Re-education was completed with current residents on site on 2/2/24. 2. Fire Safety Training will be scheduled for residents on an annual basis. New residents will receive fire safety training upon move in and annually with other residents. Training records will be stored in a binder in the Executive Director's office. 3. Re-education on fire safety training for residents will be completed annually, with education on fire safety for new residents completed as needed. 4. Executive Director, Maintenance Technician, or designee.

Based on observation and interview, it was determined the facility failed to ensure all exterior Residential Care Facility's (RCF) grounds were kept orderly, free of litter and refuse. Findings include, but are not limited to: Observations of the facility grounds on 10/16/23 revealed the following: A large rusted generator with numerous exposed wires along with several pieces of polyvinyl chloride (PVC) pipe and an opened bag of potting soil lying next to the generator. The facility's exterior grounds were toured with Staff 1 (ED) on 10/18/23. She acknowledged the findings.

1. Pieces of PVC pipe and potting soil were removed. Maintenance Manager contact Regional Maintenace Tech for further guidance regarding removal of the generator. 2. Exterior areas of the building will be regularly inspected at least once monthly and cleaned as needed. 3. Inspection of the community grounds will be completed monthly. 4.Maintenance Manager and Executive Director or designee.

Based on observation and interview, it was determined the facility failed to ensure all exterior Residential Care Facility's (RCF) grounds were kept orderly, free of litter and refuse. This is a repeat citation. Findings include, but are not limited to: Observations of the facility grounds on 01/29/24 through 02/01/24 revealed the following: The courtyard was observed with drop-offs up to approximately two inches from the sidewalk to the rock landscape near the west courtyard door and a raised portion of sidewalk on the walking path which created tripping hazards. Debris of multiple disposable coffee cups, empty cigarette packages and dog excrement was also observed in the courtyard area. The facility's exterior grounds were toured with Staff 6 (RCC) and discussed with Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1. River rock was raked into the south corner of the courtyard to eliminate the drop off beside the sidewalk. The courtyard and gazeebo areas were cleaned. Apartment doors were repainted. 2. Regular inspection of the courtyard will be completed by front desk staff. Staff will clean the gazebo and empty any trash. Staff will document this daily task on a task sheet to be reviewed by Business Office Coordinator weekly. Staff will create work orders for any items in need of repair.  Weekly walkthroughs of the courtyard and exterior grounds will be completed by Maintenance Technician to verify items are in good repair. Inspections will be documented on weekly building inspection form. Work orders will be created as needed and repairs will be made in a timely manner. 3. Daily cleaning for the courtyard, weekly inspection of courtyard and building exterior and repairs will be made as needed. 4. Executive Director or designee

Based on observation and interview, it was determined the facility failed to ensure the interior surfaces were kept clean and in good repair and free of unpleasant odors. Findings include, but are not limited to: The interior of the building was toured on 10/16/23 through 10/18/23. The following areas were observed to need cleaning and/or repair: * Multiple resident doors on the first, second and third floors had scuffs and dings; * All doors leading to the interior courtyard had scuffs and dings; * Both elevator doors and frames had scuffs and dings; * The carpet was stained in front of the elevator near the electrical north room, and the inside of the elevator had stained and scuffed flooring and scuffed walls; * The washers and dryers in the laundry room on the second floor had dirt and debris. The shelf above the washers and dryers was stained with soap residue; and * Pervasive urine odors were noted on the third floor near room 310. The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (ED) on 10/18/23. She acknowledged the findings.

1. All apartment and courtyard doors have been inspected, cleaned and painted/repaired as needed. Laundry room and carpets were also cleaned. Elevator walls and floor were cleaned. 2. Common area surfaces and carpets have been placed on a cleaning schedule and will be cleaned monthly, spot cleaning will be completed as needed. Apartment door exterior cleaning will be added to weekly housekeeping assignments. Immediate repairs will be completed as needed. Maintenance and Executive Director will conduct a weekly walkthrough of all community common areas to note any areas in need of cleaning/repair. 3. Scheduled cleaning/painting will occur monthly.  Weekly walkthrough will note areas of immediate need. 4. Maintenance Manager and Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure interior surfaces were kept clean and in good repair and free of unpleasant odors. This is a repeat citation. Findings include, but are not limited to: The interior of the building was toured on 01/29/24 through 02/01/24. The following areas were observed to need cleaning and/or repair: * Multiple resident doors on the first, second and third floors had scuffs and dings; * All doors leading to the interior courtyard had scuffs and dings; * The courtyard door near the electrical north room loudly banged when closed; * Both elevator doors and frames had scuffs and dings; * The inside of the elevator near the electrical north room, had scuffed flooring and scuffed walls; * The stairwells had stained carpets and debris; * The washers and dryers in the laundry room on the second floor had dirt and debris; * The first pillar in the dining room had a hole in the upper portion of the drywall; * The kitchen alcove near the kitchen entrance had scuffs, dings, chipped and worn away paint leaving exposed wood on the dividing wall, and a gap between the floor and wall near the kitchen entrance had collected dirt and debris; and * Pervasive urine odors were noted on the third floor near room 310. The areas in need of cleaning and/or repair and unpleasant odors were shown to Staff 6 (RCC) and discussed with Staff 1 (ED) on 02/01/24. They acknowledged the findings.

1. Apartment doors were repainted to address scuffs on 2/19/24. Courtyard and other doors will be repainted by 3/17/24. Carpet cleaning in the hallways was completed on 2/17/24 and was scheduled for routine cleaning. The pillar in the dining area was repaired. Additional repairs in the dining area and kitchen alcove will be completed by 3/17/24. Soiled carpet in 3rd floor apartment identified in Statement of Deficiency will be removed and replaced with vinyl flooring by 3/17/24. East elevator cleaned and request to have interior cab modernized is in process with elevator company. Stairwells will be vaccummed and spot shampooed by 3/17/24. 2. Weekly interior inspection will be completed by Maintenace Technician and documented on the weekly building inspection sheet. Work orders will be created for any repairs as needed and then completed in a timely manner. 3. Weekly interior inspections will be completed and repairs made as needed. 4. Executive Director or designee.

Based on observation, interview, and record review, it was determined the facility failed to provide adequate administrative oversight and to ensure the quality of services rendered in the facility, which posed a risk to the safety of residents. Findings include, but are not limited to: During the re-visit survey, conducted 01/29/24 through 02/01/24, oversight to ensure resident care and services rendered in the facility was found to be ineffective based on the number of repeat citations, new citations and severity of citations. Refer to deficiencies in the report.

1.The community team put immediate plans of correction in place during the survey. Each citation listed in the Statement of Deficiency was reviewed and immediate action steps were completed as detailed in this plan of correction. 2.The community team will review systems and corrections at clinical meeting and 1:1 meetings with department heads and Executive Director no less that twice weekly. The District Director of Operations and District Director of Clinical Services or their designees will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the next 30 days, then move to weekly for the following 30 days, and then monthly for the next 30 days. 3. Systems and corrections will be reviewed by community team at least twice weekly and by District team as described above. 4.The community has entered into an agreement with a department-approved Registered Nurse Consultant.  The District Director of Operations and District Director of Clinical Services or their designees will be responsbile for verifying that the corrections are made.

Based on observation and interview, it was determined the facility failed to ensure a copy of the most recent re-licensure survey, including all revisits and plans of correction, was available to residents and visitors. Findings include, but are not limited to: A tour of the facility conducted on 01/29/24 identified an outdated copy of the facility re-licensure survey from 12/15/21. The most recent re-licensure survey was conducted on 10/19/23. The need to ensure a copy of the most recent re-licensure survey, including all revisits and plans of correction, was discussed on 02/01/24 with Staff 1 (ED). She acknowledged the findings.

1. Survey results from Kitchen inspection dated 4/4/2023, relicensure survey dated 10/19/2023, and 1st revisit survey dated 2/1/2024 were placed in a binder in the lobby, accessible to residents, families, and visitors. 2. The Executive Director or designee will be responsible to update the binder with survey results upon receipt. 3. Survey results will be updated as needed with each new inspection. 4. Executive Director or designee

Based on observation, interview, and record review, it was determined the facility failed to provide a homelike environment for 1 of 1 sampled resident (#9) and multiple unsampled residents. Findings include, but are not limited to: 1. During the survey from 01/29/24 through 02/01/24, pervasive odors were observed throughout the third-floor corridor. The facility windows were opened at each end of the 3rd floor corridor on 01/29/24 - 01/31/24. The outdoor temperatures during the survey ranged between 40's and 50's in the late afternoon hours. The indoor ambient air temperature on the third floor was cold and a draft was felt throughout the third floor. During the survey multiple unsampled residents residing on the third-floor verbalized complaints about the odor. The need to provide a homelike environment for residents was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings. 2. Resident 9 was admitted to the facility in 03/2017 with diagnoses including chronic obstructive pulmonary disease (COPD) and Type 2 diabetes mellitus. Resident 9's evaluation and service plan dated 01/12/24 noted the resident required staff assistance with bladder and bowel incontinence care which often resulted in additional assistance related to hygiene and housekeeping. The resident was dependent on two caregivers for all transfers and used a manual and/or electric wheelchair for mobility. During an interview with Resident 9 in his/her apartment, the carpet was observed to be sticky when walked on, had multiple large stains that covered much of the floor, and the apartment had a pervasive odor. During the interview Resident 9 stated the carpets had "not been cleaned since [s/he] moved in." The resident further stated "I wouldn't live this way if it was my house. I'm one of those fussy old [gender reference] that likes things clean." The need to provide a homelike environment for residents was discussed with Staff 1 (ED) on 01/31/24. She acknowledged the findings.

1. Resident 9 was voluntarily relocated to an apartment on the same floor of the same size that had new flooring. The carpet in the old apartment will be replaced. 2. Carpet cleaning for common areas and resident apartments has been scheduled. Community walkthroughs will be completed including visual inspections of each resident apartment and common areas. As needed vaccuming or shampooing of carpets will be added as a work order with the front desk. 3. Common areas will be inspected weekly and each resident apartment will be inspected monthly. 4. Executive Director, Maintenance Technician, or Designee

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 3 of 3 sampled residents (#s 7, 9 and 10). Findings include, but are not limited to: Resident 7, 9 and 10's current service plans were reviewed during the survey. The service plans lacked evidence a Service Planning Team reviewed and participated in the development of the service plans. The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (ED) on 02/01/24. She acknowledged the findings.

1. Care conferences were scheduled for Resident 7 (2/23/24), Resident 9 (2/23/24), and Resident 10 (2/27/24) to review their current service plans. Letters were provided to the residents and family was notified. Residents were encouraged to invite anyone they chose to participate in their care planning process. 2. Executive Director will be responsible for scheduling care conferences and communicating them to residents and families. Residents will be encouraged to invite anyone they'd like to participate in their care planning process.   3. Care conferences will occur with each service plan update including: at move in, 14-30 days after move in, every 90 days thereafter, and as needed for changes in condition. 4. Executive Director and/or Designee.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C252, C260, C270, C280, C290, C303, C310, C361, C422, C510, and C513.

1. The community team will create and implement a revised plan of correction for C252, C260, C270, C280, C290, C303, C310, C361, C422, C510 and C513. 2.The District Director of Operations, District Director of Clinical Services and Brookdale clinical specialists will connect with the community team a minimum of twice weekly via in person visits, training/support calls, and/or remote documentation review. This additional monitoring will continue for the next 30 days, then move to weekly for the following 30 days, and then monthly for the next 30 days. 3. Will be reviewed with District team as described above. 4.The community has entered into an agreement with a department-approved Registered Nurse Consultant.  The District Director of Operations, District Director of Clinical Services and their designees will be responsible for verifying that the corrections are completed.

Based on observation, interview, and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to: Refer to: C 260, C 361, and C 455.

1. The community team will create and implement a revised plan of correction for C260 and C361. 2. The community team will continue to coordinate with the District Management team to ensure compliance with corrections on a regular and as needed basis. Executive Director will work with community team to review compliance during daily stand-up and clinical meeting as well as regular monthly review of systems. 3. District Team will complete site revists on a scheduled basis as well as Executive Director review at least weekly to ensure compliance with both plan of correction and ongoing overall compliance. 4. District Management and Executive Director.

The findings of the re-licensure survey conducted 10/16/23 through 10/19/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 10/19/23, conducted 01/29/24 to 02/01/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the second revisit to the re-licensure survey of 10/19/23, conducted 05/28/24 through 05/29/24, are documented in this report. The survey was conducted to determine compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 for Home and Community Based Services Regulations. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the third revisit to the re-licensure survey of 10/19/23, conducted on 03/12/2025, 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 and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview and record review, conducted during a site visit on 07/28/23, it was confirmed the facility failed to ensure the staff person who administers the medication must visually observed the resident take the medication for 1 of 1 sampled resident (# 5) whose chart was reviewed. Findings include, but are not limited to: Resident 5's medical chart indicated s/he had a self-administration order from his/her physician. A review of Resident 5's 07/2023 MAR indicated the resident was receiving his/her medications, the facility was documenting the administration of Resident 5's medications. Many medications on MAR were written with the note that they are supervised self-administration. In separate interviews on 07/28/23, Staff 1 (Administrator), Staff 2 (Med Tech) and Staff 3 (Med Tech) stated staff set up medications for Resident 5 and deliver them to resident's room and leave them for resident to take, if the resident has not taken his/her medication the next time staff enter, then staff remind resident that s/he needs to take his/her medication. In an interview on 07/28/2023, Staff 1 stated resident has had a self-administration order since they moved into the facility and the facility and resident came to an understanding that the facility would store and set-up residents medications and leave them for resident to take and provide reminders to take medications. On 07/28/23 at 12pm, Staff 2 was observed to deliver medications to Resident 5 and leave medication cup on residents walker tray. The facility failed to ensure that a resident that self-administers their medication has an approved physician order, has been evaluated to self-administer at least quarterly and keep prescriptions in their unit. The findings of the investigation were reviewed with and acknowledged by Staff 1 on 08/01/2023. Verbal Plan of Correction: Staff 1 will be in contact with Resident 5's physician to get clarification on orders and request orders be corrected to leave at bedside as it is Resident 5's preference for facility to manage medications but leave them for resident to take. Staff 1 anticipates receiving clarification and updating Resident orders by the end of the week (08/04/2023).

Based on interview and record review, conducted during a site visit on 07/28/2023 it was determined the facility failed to implement an acuity-based staffing tool (ABST) that met the regulation for 3 of 3 sampled residents (#s 2, 3 and 4). Findings include, but are not limited to: In an interview on 07/28/2023, Staff 1 (Administrator) stated the information from resident service plans feeds into the facility's ABST system which generates a staffing plan, and this is automatically updated whenever a service plan is updated. A review of the facility's ABST indicated the tool failed to include all of the 22 required ADL components to include: * Repositioning in bed or chair; * Assisting with leisure activities; and * Responding to call lights. The facility failed to fully implement an acuity-based staffing tool that met regulations. The findings of this investigation were reviewed with Staff 1. No additional information was provided. Verbal plan of correction: As stated by Staff 1  "Per my upper management, our communities are in process of working with Corrective Action on reviewing Brookdale ' s Acuity Based Staffing Tool. There have been multiple calls and communications with the Department and we are continuing to partner and evaluate our tool as well as where the 22 required elements are identified. As we work through our Acuity Based Staffing Tool (ABST) with the department, we will continue to staff using Brookdale's tool. We will continue to evaluate and modify our staffing needs through our resident assessment process to include upon move in, change of condition, or quarterly. "

The findings of the on-site investigation, conducted 07/28/2023, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities. Abbreviations possibly used in this document: ADL: activities of daily living CBG: capillary blood glucose or blood sugar CG: caregiver CS: Compliance Specialist cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MT:            Medication Tech MAR: Medication Administration Record MCC: Memory Care Community OT: Occupational Therapist PT: Physical Therapist PRN: as needed RCC: Resident Care Coordinator RN: Registered Nurse

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/04/23 at 10:50 am, the facility was observed to need cleaning in the following areas: Food spills, splatters, debris, grease, dust/dirt and/or black matter was observed on or beneath the following: * Lower shelves throughout the entire kitchen (beneath steam table, juice and coffee station, food prep counters); * Hood vents above the stove;   * Wire shelves on wall near the steam table/refrigerator (above recycling container); * Tub on bottom shelf under toaster containing soup bowls; * Oven doors and handles; * Top and doors of convection oven: * Wall behind convection oven and above shelf of stove; * Wall behind steamer; * Walk in refrigerator walls and ceiling; and * Floor beneath counters/sinks/prep areas/racks throughout the kitchen. Garbage can near ice machine was uncovered when not in use. The areas above were discussed with Staff 1 (Dietary Services Manager), Staff 2 (Executive Director) and Staff 3 (Business Office Staff) on 04/04/23. The findings were acknowledged.

1.  Entire kitchen will be deep cleaned on 5/3/2023 including: removing food spills/splatters, debris, grease, dust/dirt and/or black matter from lower shelves throughout the entire kitchen (beneath steam table, juice and coffee station, food prep counters); hood vents above the stove were cleaned; wire shelves on wall near the steam table/refrigerator (above recycling container); tub on bottom shelf under toaster containing soup bowls; oven doors and handles; top and doors of convection oven: wall behind convection oven and above shelf of stove; wall behind steamer; walk-in refrigerator walls and ceiling; and the floor beneath counters/sinks/prep areas/racks throughout the kitchen. Garbage can near the ice machine cover on 4/4/2023. On 4/18/2023 the Dining Services Coordinator received additional training on the cleaning requirements and cleaning schedule per the Dining Services manual and the responsibility of holding staff accountable to the schedule. 2. By 4/30/2023 all kitchen associates will undergo inservice on kitchen cleaning procedures. Dining Services Coordinator will routinely review daily, weekly, and monthly cleaning checklists. Executive Director will completely weekly audit of cleaning checklists and visual inspection to ensure compliance of a clean and sanitary kitchen. 3. Daily inspections Monday-Friday by Dining Service Coordinator or designee. Weekly review and visual inspection by Executive Director. 4. Daily inspections Monday-Friday by Dining Service Coordinator or designee. Weekly review and visual inspection by Executive Director.

The findings of the kitchen inspection, conducted 04/04/23, 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 Sanitation Rules OARS 333-150-0000.

The findings of the first revisit to the kitchen inspection of 04/04/23, conducted 07/06/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

2. Resident 5 moved into the facility in September of 2020 with a diagnosis of cerebral vascular accident. Review of Resident 5's record revealed s/he experienced a skin tear to the top of his/her left hand on 12/01/21. There was no incident report written until 12/06/21 and final Administrator review was not completed until 12/07/21. Interview with Staff 2 (Health and Wellness Director) on 12/14/21, about the incident on 12/01/21, revealed the facility failed to promptly investigate this incident. The need to ensure resident incidents were investigated timely including administrative review was discussed with Staff 1 (Executive Director) on 12/14/21. He acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure resident incidents were thoroughly investigated in a timely manner and/or reported to the local Seniors and People with Disability (SPD) office for 2 of 3 sampled residents (#s 2 and 5) who were reviewed for injuries of unknown cause and a medication error. Findings include, but are not limited to: 1. Resident 2 moved into the facility in October 2021 with a diagnosis of congestive heart failure. Review of Resident 2's record revealed s/he was administered the wrong medications on 11/24/21. Interview with Staff 1 (ED) on 12/14/21, about the incident on 11/24/21, determined the facility failed to report the medication error to the local SPD office and the administrator review was not completed until 11/30/21, six days after the incident occurred. The surveyor requested Staff 1 report the incident to the local SPD office. Confirmation of the self report to the local SPD office was received on 12/14/21. The need to ensure resident incidents were thoroughly investigated, including timely administrative review and reported to local SPD office when abuse and neglect could not be ruled out was discussed with Staff 1 on 12/14/21. He acknowledged the findings.

1)  APS notified on 12/14/2021 for resident 2 receiving the incorrect medication.  Resident 5 incident report and investigation related to skin tear completed on 12/6/2021. 2)  At daily clinical meeting incident reports will be reviewed and investigations completed.  APS will be notified immediately when appropriate.  ED, RN and RCC will be trained on abuse reporting policy by Area Nurse Manager during the week of 1/10/2022. 3)  This will be evaluated daily at clinical meeting. 4) Health and Wellness Director and Executive Director, or designee.

2. Resident 1 was identified as a smoker during the acuity interview on 12/13/21. Resident 1's service plan, dated 10/01/21, stated resident was a smoker. An interview with Staff 5 (RCC) on 12/15/21 confirmed Resident 1 smoked daily. Although smoking was documented on the service plan, there was no documented evidence a smoking safety evaluation had been completed since the initial move in on 08/17/21. An interview with Staff 2 (Health and Wellness Director) on 12/13/21 verified that no quarterly smoking evaluation had been completed for resident. The facility's failure to complete a quarterly smoking evaluation was discussed with Staff 1 (Executive Director), Staff 2 (Health and Wellness Director) and Staff 12 (Area Nurse Manager)  on 12/15/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a move-in evaluation was completed addressing all elements, was updated within 30 days, and quarterly evaluations were completed for 2 of 4 sampled residents (#s 1 and 2) whose new move-in evaluation and quarterly evaluations were reviewed.  Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure. The resident's move-in evaluation was incomplete, as the following areas were not addressed and/or answered: * Visits to health practitioner, ER, hospital, or nursing facility in the past year; * History of dehydration or unexplained weight loss or gain; and * Recent losses.   At the time of the survey, the 30 day update had not been completed and was overdue by 16 days. The need to ensure all elements in the move-in evaluation were addressed and ensuring the evaluation was updated within 30 days was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 3 (Area Nurse Manager) on 12/13/21. Staff 2 completed the 30 day update during the survey.

1)  Missing documentation for resident 2 has been completed and 30 day service plan updated was completed on 12/13/2021.  Smoking evaluation for resident 1 has been completed on 1/3/2022. 2)  New move in checklist will be utilized for all new residents, including but not limited to, areas noted in statement of deficiencies.  Quarterly evaluation checklist will be completed with each service plan update to ensure all ancillary evaluations are completed at the time of review. 3)  Review will occur daily at clinical meeting. 4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to ensure resident service plans were reflective of resident needs and provided clear direction to staff regarding the delivery of services for 2 of 6 sampled residents (#s 1 and 2) whose service plans were reviewed. Findings include, but are not limited to: 1.  Resident 1 was admitted to facility August of 2021 with diagnosis of history of alcoholism. Resident 1 was observed sleeping in room with door open daily throughout survey. Multiple beer cans were observed in the resident's sink and table next to recliner. In an interview with Staff 5 (RCC) on 12/15/21 at 10:35 am, she verified that the resident drank daily which led to falls and missed medications when the resident did not want to be woken up. A review of the resident's most recent service plan, dated 10/01/21, revealed it was not reflective of daily alcohol consumption, falls that were related to resident's drinking, or inappropriate comments to staff while drinking. The need to ensure the service plan was reflective of the resident's status and care needs was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings. 2.  Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure. During an interview and observations with Resident 2 on 12/14/21 at 9:30 am, the resident was observed to have the left lower leg wrapped. Resident 2 stated hospice was helping care for his/her leg however, was unable to state what had happened. In an interview with Staff 5 (RCC) on 12/15/21 at 1:15 pm, she verified that the resident had an open wound on the left lower leg and that s/he had multiple incidents of confusion, an incident of disturbance of other residents, diminished orientation to time, and periods of anxiety. Resident 2's most recent service plan, dated 12/13/21 did not provide clear instructions to staff on the delivery of care and services and was not reflective of the resident's current status in the following areas: * Skin concerns related to wound care and monitoring; and * Cognitive status related to orientation, confusion and anxiety. The need to ensure the service plan was reflective of the resident's status and provided clear instructions for staff was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

1)  Care plan for resident 1 was updated on 1/3/2022 to reflect daily alcohol consumption, alcohol related falls and reported inappropriate comments while drinking.  Care plan for resident 2 was updated on 1/3/2022 to provide clear instruction to staff on cognitive changes and skin monitoring. 2)  All care plans will be reviewed by care plan team and resident/family to ensure accuracy and updates will be made as needed.  TSP's and 3rd party notes will be reviewed at clinical meeting and written onto care plans as appropriate.  Training has been scheduled the week on 1/10/2022 with the Area Nurse Manager to review service plans with ED, RN and RCC.  Community RN has also been scheduled to complete the next scheduled Role of the RN in Community-Based Care training through OHCA from 3/1/2022-3/3/2022. 3)  Daily at clinical meeting and with each care plan update. 4)  Health and Wellness Director and Executive Director, or designee.

2. Resident 5 was admitted to the facility in 09/2020 with a diagnosis of cerebral vascular accident. Observations, interviews and review of the resident's current service plan, temporary service plans and weight records were conducted during the survey. Resident 5 had the following significant change of condition: * Weight records dated 01/05/21 through 10/08/21 were reviewed and indicated the resident experienced a 22 pound unplanned weight loss between 07/28/21 and 10/13/21. Resident 5's records revealed the following weight's: * 07/28/21: 219.6 lbs.; and * 10/13/21: 197.6 lbs. This loss of over 10% of body weight constituted a significant change of condition for severe weight loss. There was no documented evidence interventions were reviewed for effectiveness, new interventions determined, documented and communicated to staff regarding the weight loss. The need to ensure changes of condition were evaluated, actions and interventions determined and monitored for effectiveness was discussed with Staff 1 (Executive Director) and Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings. Refer to C 280.

Based on observation, interview and record review, it was determined the facility failed to determine and document what action or intervention was needed, communicate resident-specific interventions to staff and document weekly progress until the condition was resolved for 2 of 5 sampled residents (#s 2 and 5) who were reviewed for changes of condition. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 10/2021 with a diagnosis of congestive heart failure and was receiving hospice services. Observations, interviews and review of the resident's current service plan and temporary service plans were conducted during the survey. Resident 2's initial service plan identified the resident as a fall risk and universal fall precautions were service planned. Resident 2 had the following short-term changes of condition: * Fall on 11/09/21; * Fall on 11/17/21; * Wrong medications administered on 11/24/21; and * Change in cognition on 12/01/21 and 12/04/21. There was no documented evidence that interventions were reviewed for effectiveness, new interventions determined, documented and communicated to staff after each fall. In addition, the changes of condition related to administration of the wrong medications and changes in cognition were not monitored weekly until resolved. The need to ensure changes of condition were evaluated, actions and interventions determined with weekly progress of the condition until resolved was discussed with Staff 1 (Executive Director) and Staff 2 (RN) and Staff 12 (Area Nurse Manager) on 12/14/21. They acknowledged the findings.

1)  APS notified on 12/14/2021 of wrong medication for resident 2.  Fall interventions have been reviewed for effectiveness and change of condition has been completed.  Change of condition has been completed for unplanned weight loss for resident 5. 2)  Daily at clinical meeting, resident changes, including but not limited to, weight and fall interventions will be reviewed and followed up on as appropriate.  Community wil also complete a collaboritive care review each month in which every resident will be reviewed by department head team.  ED, RN and RCC received training on change of condition monitoring from DDCS/RN. 3)  Daily for any resident changes and monthly for all residents 4)  Health and Wellness Director and Executive Director, or designee.

Based on observations, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#5) who experienced a significant change of condition related to weight loss. Findings include, but are not limited to: Resident 5 was admitted to the facility in September 2020 with diagnoses including cerebral vascular accident.   Weight records dated 01/05/21 through 10/08/21 were reviewed and indicated the resident experienced a 22 pound unplanned weight loss between 07/28/21 and 10/13/21. Resident's weight record revealed: * 07/28/21 at 219.6 lbs; and * 10/13/21 at 197.6 lbs. The loss of over 10% of body weight constituted a significant change of condition for severe weight loss. A progress note dated 10/13/21 stated the RN was aware of the weight loss. The facility failed to ensure an RN assessment was completed with documented findings, resident status and interventions made as a result of the assessment. Multiple observations of the resident between 12/13/21 and 12/15/21 showed the resident eating in the dining room independently. In an interview on 12/15/21, Resident 5 stated s/he was unaware of the weight loss. The resident stated s/he "would love to lose weight".   The need to ensure an RN assessment was completed which included the required components of documented findings, resident status and interventions made as a result of the assessment was discussed in interview on 12/14/21 with Staff 2 (Health and Wellness Director) and Staff 12 (Area Manager RN). Staff 2 noted that Resident 5 did not like to be weighed and often refused. In an interview on 12/15/21, Staff 1 (Executive Director), Staff 2 and Staff 12 acknowledged the findings.

1)  Change of condition for resident 5 has been completed regarding unplanned weight loss and reviewed with resident. 2)  Resident health changes will be reviewed and discussed daily at clinical meeting.  All residents will be reviewed monthly by department head team at collaboritive care review.  ED, RN and RCC have scheduled training with DDCS/RN including RN assessment and change of condition monitoring. 3)  Daily for resident changes and monthly for all residents. 4)  Health and Wellness Director and Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure recommendations were implemented for 1 of 1 sampled resident (#2) who was receiving services from outside providers. Findings include, but are not limited to: Resident 2 was admitted to the facility in 10/2021 with diagnoses including congestive heart failure and was receiving hospice services. A review of Resident 2's clinical record identified the following hospice recommendation was not implemented: * 12/6/21, MT to observe and monitor left lower leg bandage for saturation or dislodgement of the bandage. Notify hospice. There was no documented evidence the recommendation was communicated to staff, made part of the resident's service plan, or implemented. The need to ensure the facility coordinated care with outside service providers and implemented recommendations was discussed with Staff 1 (Executive Director), Staff 2 (RN) and Staff 12 (Area Nurse Manager). They acknowledged the findings.  During the survey, Staff 12 added the recommendation with three times per day monitoring to the December MAR.

1)  During survey the care plan and MAR for resident 2 were updated to reflect instructions from outside provider. 2)  Outside provider notes will be reviewed at daily clinical meeting and updates will be made to resident records as appropriate.  ED, RN and RCC have scheduled training the week of 1/10/2022 with Area Nurse Manager including outside provider follow up. 3)  Daily at clinical meeting. 4)  Health and Wellness Director and Executive Director, or designee.

Based on interview and record review, it was determined the facility failed to notify the physician when a resident refused to consent to orders for 1 of 1 sampled residents (#1) who had documented medication refusals. Findings include, but are not limited to: Resident 1's clinical records and MARs were reviewed during the survey and revealed the resident had multiple medication refusals between 11/06/21 and 12/04/21. There was no documented evidence the facility notified the physician when the resident refused consent to their orders. On 12/15/21 the failure to notify physicians of the documented medication refusals was reviewed with Staff 1 (Executive Director), Staff 2 (Health and Wellness Director) and Staff 12 (Area Manager RN). They acknowledged the findings.

1)  Physician was notified of medication refusals by resident 1. 2)  Med Techs received training from Area Nurse Manager on 12/14/2021 on notifying physicians of every refused medication and documentation.  Daily at clinical meeting all medication refusals and notifications will be reviewed for completion.  Any missed notifications will be completed at this time. 3)  Daily at clinical meeting. 4)  Health and Wellness Director and Executive Director, or designee.

Based on observation, interview and record review, it was determined the facility failed to have a sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to: The facility was licensed as a Residential Care Facility (RCF) that was home to 70 residents. The RCF had three floors accessible by stairs and elevators. 1. During the entrance conference on 12/13/21, the following was identified regarding resident care needs: * Two residents needed two-person assist with transfers or Hoyer; * Two residents were on hospice; and * Six residents were identified as having recent falls. 2. Observations and interviews conducted between 12/13/21 and 12/15/21 showed the following: * During interviews, several staff confirmed the facility was short staffed; * Caregivers were observed doing laundry for residents, providing tray service to rooms during mealtimes, and assisting the kitchen to serve meals in the dining room; * In an interview with a non-sampled resident on 12/14/21, s/he said "Most of the time on night shift we only have one caregiver and one MT for all three floors. I don't usually use my call light for help, but one night I choked, and it took one and half hours before someone came to help me. I don't feel safe here."; * Interview with non-sampled resident on 12/14/21, s/he said "I'm in a lot of pain, so I don't go to the dining room for meals, it's too difficult. I get a meal tray and you're taking chances on it being hot. I don't call for help because it takes 30 minutes or more to get help here and I don't have time to wait."; * Interview with non-sampled resident on 12/14/21, s/he stated "When I fill out my ticket for a meal tray I either don't get the tray or it's cold when I get it."; * During an interview with Resident 5 on 12/15/21, s/he stated there aren't enough staff here". Resident 5 stated "on every shift" when asked if it was at a specific time of day; and * During an interview with Staff 13 (CG) on 12/15/21, s/he said "We have three caregivers and two MT's on shift today, but usually we only have three caregivers and one MT on first shift.". 3. The staffing plan for November 2021, provided by the facility was as follows: The staffing plan that was posted at the time survey entered was as follows: Day: 4 CG's and 2 MT, total 6 staff; Swing: 3 CG's and 2 MT, total 5 staff; and Night: 3 CG's and 1 MT, total 4 staff. The November staffing schedule noted the following dates were not staffed accordingly: Day shift: 11/1/21 -11/6/21,  11/8-11/13 and 11/15 -11/27/21 noted three to four staff were scheduled (two to three staff short). Swing shift: 11/1/21 -11/5, 11/8 -11/13, 11/15-11/23, 11/25-11/30/21 noted three to four staff were scheduled (one to three staff short). Night shift: 11/1/21 -11/5, 11/8 -11/12, 11/15-11/19, 11/22 -11/26 and 11/29 -11/30/21 noted three staff were scheduled (one staff short). 4. The staffing plan (revised during survey) for December was as follows: Day shift: 4 CG's and 1 MT's, total 5 staff; Swing shift: 3 CG's and 1 MT's, total 4 staff; and Night shift: 2 CG's and 1 MT, total 3 staff. The December staffing schedule noted the following dates were not staffed accordingly: Day shift: 12/2/21 -12/6/21 noted three to four staff scheduled (One to two staff short). Swing shift: 12/2/21, 12/9/21, 12/21/21, 12/24/21, 12/25/21, and 12/26/21 noted two to three staff scheduled (one to two staff short). Night shift: 12/1/21, 12/2/21, 12/8-12/11, 12/15- 12/16, 12/21-12/23, and 12/29/21 noted two staff were scheduled (One staff short). During an interview with Staff 1 (Executive Director) on 12/15/21, it was reported the facility was aware that staffing was an issue. Staff 1 said the facility had six staffing agency contracts however, they were not using agency staff at this time. Staff 1 reported, when needed, all management team will cover caregiver shifts. Upon review of the November and December staffing plan there were multiple occasions when Resident Care Coordinators (RCC) were performing MT duties rather than their assigned RCC duties, and there was no documented evidence the remaining open shifts were filled by management or other staff. The facility's failure to ensure adequate staffing in order to meet the scheduled and unscheduled needs of the residents was shared with Staff 1, Staff 2 (RN), Staff 3 (Business office Coordinator) and Staff 12 (Area Nurse Manager) on 12/15/21. They acknowledged the findings.

1)  Staffing posting has been reviewed for accuracy and updated to reflect current staffing needs. 2)  Staff schedule will be reviewed and updated at clinical meeting daily to ensure accurate reflection of shifts worked by all staff members.  Staffing agency contracts in place and contract labor will be utilized as needed to ensure adequate staffing numbers are met. 3)  Schedule will be reviewed daily at clinical meeting. 4)  Health and Wellness Director and Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to: Observations of the facility on 12/14 - 12/15/21 revealed the following areas were in need of cleaning and/or repair: * Multiple resident apartment doors throughout the facility had black scuff marks, missing paint and/or gouges; * The elevator entrance by apartment 104 had a gouge in the wall exposing the sheetrock below; * The elevator by apartment 340 had black scuff marks and a panel that was broken at the bottom exposing the wood underneath; and * The carpet in the hallway outside apartment 340 had several stains. The environment was toured and the need to maintain interior surfaces clean and in good repair was discussed with Staff 1 (ED) on 12/15/21 . He acknowledged the findings.

1)  All apartment doors have been inspected, cleaned and painted/repaired as needed.  All other areas noted in the statement of deficiencies have been corrected. 2)  Common area carpets have been placed on a cleaning schedule and will be cleaned monthly, spot cleaning will be completed as needed.  Apartment doors are on a monthly cleaning/painting schedule.  Immediate repairs will be completed as needed.  Maintenance and Executive Director will conduct a weekly walkthrough of all community common areas to note any areas in need of cleaning/repair. 3)  Scheduled cleaning/painting will occur monthly.  Weekly walkthrough will note areas of immediate need. 4)  Maintenance and Executive Director, or designee.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. This is a repeat citation. Findings include, but are not limited to: During an environmental tour of the facility revealed the interior of the elevator, by Resident Apartment 140, had black scuff marks on the walls, and a panel was broken at the bottom exposing the wood underneath. On 3/01/22, Staff 1 (ED) and the Surveyor toured the environment and discussed the need to ensure interior surfaces were clean and in good repair. He acknowledged the findings.

1)  Elevator cab has been inspected, cleaned and sanded to ensure no safety risks exist. 2)  Elevator cab is scheduled to be refurbished.  Currently waiting on TK Elevator to receive necessary parts to start work. 3)  Elevator cab will be inspected weekly to ensure continued safety until work to refurbish cab is completed. 4)  Executive Director, or designee, will be responsible for continued monitoring.

Based on observation, interview and record review, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Division. Findings include, but are not limited to: Refer to C 513.

See POC for tag C513

The findings of the re-licensure survey conducted 12/13/21 through 12/15/21 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and OARs 411 Division 004 Home and Community Based Services Regulations. 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 revisit to the re-licensure survey of 12/15/2021, conducted 02/28/22 through 03/01/22, 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 and Home and Community Based Services Regulations OARs 411 Division 004. 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 12/15/21, conducted on 04/19/22, 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.