Fieldstone Village at Keizer Ridge Memory Care

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: Observation of the facility main kitchen and memory care kitchenette occurred on 02/17/26, from 10:15 am through 1:15 pm found the following: 1) Main Kitchen Areas: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Top of juice machine; * Top of service line; * Behind oven/range/grill top; * Industrial can opener and housing; * Industrial mixer; * Cooling fan in front of reach-in cooler; * Cooling fan cages in walk-in cooler; * Metal racks in walk-in cooler; * Ceiling and piping/conduit in walk-in cooler; * Floors under racks in walk-in freezer; * Floor drains; * Interior and exterior of steamer; * Wall above hand wash sink near hood; * Removable hood vents; * Celling vent above back food prep area; * Interior of ice machine with black debris/other build up; * Interior of microwave; * Interior of blender base; * Drain under sink in dining room beverage area; and * Interior of drawers under coffee station in dining room. b. The following areas needed repair: * Rust and peeling paint on metal racks in reach-in coolers; * Black debris build-up on caulking behind dirty side of ware washer area; * Rust on metal shelving in reach-in cooler; * Steamer not operational; * Reach-in cooler not holding proper temperatures; * Multiple drainage hoses were observed stored deep inside floor drains, causing potential for back flow issues if drains backed up and flooded.; and * Cracked/chipped lid on trash can next to hand washing sink. c. Commercial mixer with food contact surface of bowl and paddle stored uncovered when not in use. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. e. Multiple opened food items stored greater than 24 hours observed without open or prepared dates. Multiple food items found past seven days from prepared dates and should have been discarded. f. Multiple food packages were found open in freezer, exposing food products to potential contamination and food quality issues. g. Large two-door reach-in cooler thermometer on the outside was noted at 60 degrees F. The inside thermometer was found at greater than 50 degrees F. Staff 2 (Dining Services Director) checked the temperature of a boiled egg, and it was found at 45 degrees F. The facility was not able to produce temperature logs for that unit to determine how long the unit was not holding proper temperatures. Staff 2 checked the temperature of food items and discarded all food out of acceptable temperatures and moved all other food to the walk-in cooler. Staff 2 was not aware of that unit having issues holding temperatures. 2) Memory Care Kitchenette a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following: * Interior of reach-in refrigerator; and * Interior of microwave. b. The following areas needed repair: * Cracked/chipped trash can lid needed to be repaired or replaced; * Reach-in refrigerator was found at 50 degrees F and not holding proper cold food storage temperatures. c. Multiple opened food items stored greater than 24 hours were observed without open or prepared dates. Multiple food items found past manufacturer’s use-by dates and should have been discarded. d. A plastic zip bag of sliced cheese was found open, exposing the food product to potential contamination, with visible drying and quality concerns. A bag of sliced turkey breast for sandwiches was observed without at date, and the color was off. Surveyor opened the bag and a foul smell immediately arose from the bag, indicating the food product was spoiled and needed to be discarded. e. The interior thermometer of the reach-in refrigerator was found at 50 degrees F. A container of yogurt stored inside the refrigerator was tested and found at 47 degrees F. Care staff in the unit were interviewed and indicated they were not checking/monitoring temperatures of the refrigerators and believed maintenance was, but did not know the frequency. Staff were not checking/monitoring dates of food products. Staff 2 was informed and did not know who was to be monitoring the temperatures of the refrigerator in the kitchenette. She acknowledged that the temperature was too high and that they would review items in that refrigerator and discard food items. A maintenance staff member was interviewed and they indicated they do check on refrigerator temperatures, but only if care staff indicate there are concerns. The staff was unaware of any reported concerns with that refrigerator. Staff 1 (Executive Director), Staff 2, and Staff 3 (Memory Care Administrator) acknowledged a system for monitoring food storage temperatures and dates of food was needed. At approximately 1:00 pm, surveyor reviewed above areas with Staff 1, Staff 2, and Staff 3, who all acknowledged the identified areas.

Plan of Correction for C240: 1)Main Kitchen Areas: a)Upon notification the dining director, maintenance staff immediately conducted a deep Clean of the kitchen and food storage areas. The following areas were cleaned and sanitized -Juice maching _Top of the service line -Industrial mixer -behind oven/range/grill top -Cooling fan in the reach in -cooling fan cages in walk in -ceiling and conduit piping in walk in cooler B) New metal racks have been ordered and will be installed. floors under racks swept and cleaned. Floor drains cleared and free of any debris. Steamer has been removed as it has been non-operational. ceiling vent above food prep area. Ice machine was taken apart and professionally cleaned by 3rd party vendor on a yearly schedule. Kitchen staff to do monthly. Chiped garbage can replaced C: Mixer Cleaned and covered after each use D:Cutting boards have been replaced with new ones kithchen staff re-educated on proper storage and cleaning protocols. E: All food items found without open or preperation dates or exceeded allowable storage were discarded immediately to prevent recurrence, kitchen staff will label and date all open prepped food.Dining Service Director will monitor compliance through daily kitchen checks and review of storage areas. Which will be monitored by weekly inspections F: All packages food packages have been properly sealed, covered, or placed in appropriate food containers to protect the food. Dining service director will monitor freezer storage practices in her daily inspections. The Dinning Service Director will monitor compliance. G:All food found in the reach cooler that were above safe temp was immediately New thermometer for both inside and outside are in place to prevent recurrence the facility has implemented daily refrigeration monitoring logs for all units. Kitchen staff will check and document temps once per shift to ensure unit is maintaining safe food storage temp All logs will be reviewed by the Dining Services Director and she will have the binder in her office readily available 2)Memory Care Kitchenette: a. A deep clean of the refrigerator and microwave has been completed. Care staff will clean the microwave after each use, and the refrigerator will be cleaned by Noc shift staff. b. The trash can lid has been replaced with a new one. A new refrigerator has been ordered. C. Care staff have disposed of the food item without open or prepared dates and food items past the manufactured date. A cleaning list has been created for staff to complete on the Noc shift and Labels with open dates have been Order for staff to use before storing any food item. d. Care staff have disposed of the food item and any other item without an open label. A cleaning list has been created for staff to complete on Noc shift and labels with open dates have been ordered for the staff to Use before storing any food items in the fridge. e. The current refrigerator will be replaced with a new one with a new thermostat F. Refrigerator temperature log has been created and care staff are obtaining the temperature twice a day and recording it. Executive Director will audit temperature logs weekly

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

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

Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Plan of correction for Z142 will be to same as C240

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

OAR 411-054-0040 (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 ensure residents who had short term changes of condition, had resident-specific instructions or interventions developed and reviewed for effectiveness and weekly progress documented until resolution for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s. The resident's 09/14/24 service plan, 07/10/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Skin tears; * Medication changes; * Loose stools/stomach upset; * Urinary tract infection; and * Multiple falls. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia. The resident's 08/29/24 service plan, 06/24/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed. The resident experienced multiple short-term changes without noted progress at least weekly until resolved and/or lacked resident-specific directions to staff in the following areas: * Edema/swelling both lower legs; * Scratches and bruising to the legs/shin area; * Scabbed areas to the upper arm, shoulder and coccyx; * Medication changes; and * Falls. The need to ensure short-term changes of condition had documentation of weekly progress until resolution and provided clear, resident-specific directions to staff was discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

1) Resident 1 will be assessed by licensed nurse to address any skin tears, medication changes, loose stools/stomach upset, urinary tract infection, and falls with interim service plans, alert charting and at least weekly nursing assessment follow up and as needed. Resident 2 will be assessed by licensed nurse to address edema/swelling in both lower legs, any scratches and/or bruising to the legs/shin area, scabbed areas to the upper arm, shoulder and coccyx, medication changes, and falls with interim service plans, alert charting and least weekly nursing assessment follow up and as needed. 2) Clinical meeting 5 days a week to include implementation/review of interim service plans and alert charting; licensed nurse to maintain and update skin log. Minimum of 20 hours of Registered Nurse in Community. 3) Daily, weekly, monthly 4) Memory Care Executive Director

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.

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

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 1 of 3 sampled residents (#1) who experienced significant changes of condition. Findings include, but are not limited to: Resident 1 was admitted to the facility in 07/2024 with diagnoses including Alzheimer’s. Observations of the resident, interviews with staff, review of the service plan dated 09/14/24, 07/10/24 through 09/24/24 progress notes, Interim Service Plans and physician communications were reviewed. The resident required full assistance from staff for ADL care. The resident was sometimes able to eat on his/her own with cues from staff. The resident required full feeding assistance from staff on other occasions. The resident was frequently anxious and distressed when out in the common areas. The resident could be distracted during mealtimes which required staff intervention to redirect back to his/her meal. Multiple observations of the resident between 09/23/24 and 09/25/24 showed the resident asleep in a recliner in the common area, asleep in his/her bed or up in a wheelchair at one of the dining room tables. The resident meal observations showed s/he missed breakfast on all three days but did have some intake for lunch and dinner. Staff were observed to fully assist the resident with meals, snacks, and drinks. The resident did not initiate any food or fluids but accepted the items staff offered. The resident was provided a health shake on two occasions during snack/hydration pass. The resident did not interact with other residents but would respond intermittently to staff interactions. Weight records for 07/2024 through 09/2024 showed the following: * An 8-pound weight loss between 07/09/24 and 08/05/24, which constituted a significant weight loss of 6.08% in one month. * A 5.8-pound weight gain between 08/05/24 and 09/12/24, which constituted a 4.7% weight gain in one month, this was not significant for the resident. The resident’s most recent weight on 09/21/24 showed an additional 3.6-pound loss since 09/12/24, this was not a significant loss for the resident. The resident was not interviewed due to his/her current cognitive impairment and anxiety. In interviews between 09/23//24 and 09/25/24, Staff 14, Staff 15, and Staff 19 (CGs) indicated the resident required full assistance with ADL care. The resident required assistance with meals from cues to full meal assistance. The resident often slept through breakfast, especially when s/he was up all night. The resident was offered snacks as well as any replacement meals when s/he was awake. The staff indicated the resident’s intake varied, but generally did not eat a lot for any of the meals. The resident had been sleeping a lot more lately. In interview on 08/30/24, Staff 1 (MCC ED/LPN) indicated she was unable to locate any significant change assessment completed related to the weight loss. The resident was having an overall decline and increased anxiety over the last few months and was admitted to hospice on 09/17/24. There was no additional documentation located to show any interventions that were initiated related to the resident’s weight loss. The facility failed to ensure an RN assessment was completed for the weight loss and gain which documented findings, resident status, and interventions made as a result of the assessment. The need to ensure an RN assessment was completed which documented findings, resident status, and interventions made as a result of the assessment was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

1) Resident 1 assessed by Registered Nurse for significant change of condition including interim service plans for change in activity of daily living assistance and interventions related to weight loss. 2) Clinical meeting 5 days/week including review of alert charting, indication for change of condition, and interim service plans in place for staff instruction. Weekly and as needed nursing assessments regarding continued alert charting, short term and significant changes of condition. Minimum of 20 hours Registered Nurse in Community. 3) Daily, weekly, monthly 4) Memory Care Executive Director

OAR 411-054-0045 (1)(a-f)(A)(C-F) Resident Health Services Resident Health Services (1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(a) Include written policies and procedures on medical emergency response for all shifts.(b) Include an Oregon licensed nurse who is regularly scheduled for onsite duties at the facility and who is available for phone consultation.(c) Assure an adequate number of nursing hours relevant to the census and acuity of the resident population. IICs must meet contract requirements concerning nursing hours.(d) Ensure that the facility RN is notified of nursing needs as identified in OAR 411-054-0034 (Resident Move-In and Evaluation) or OAR 411-054-0036 (Service Plan - General).(e) Define the duties, responsibilities and limitations of the facility nurse in policy and procedures, admission, and disclosure material.(f) Licensed nurses must deliver the following nursing services:(A) Registered nurse (RN) assessment in accordance with facility policy and resident condition. At minimum, the RN must assess all residents with a significant change of condition. The assessment may be a full or problem focused assessment as determined by the RN. A chart review or phone consultation may be performed as part of this assessment. The RN must document findings, resident status, and interventions made as a result of this assessment. The assessment must be timely, but is not required prior to emergency response in acute situations.(C) Monitoring of Resident Condition. The facility must specify the role of the licensed nurse in the facility's monitoring and reporting system.(D) Participation on Service Planning Team. If the resident experiences a significant change of condition and the service plan is updated, the licensed nurse must participate on the Service Planning Team, or must review the service plan with date and signature within 48 hours.(E) Health Care Teaching and Counseling. A licensed nurse must provide individual and group education activities as required by individual service plans and facility policies.(F) Intermittent Direct Nursing Services. If a resident requires nursing services that are not available through hospice, home health, a third-party referral, or the task cannot be delegated to facility staff, the facility must arrange to have such services provided on an intermittent or temporary basis. Such services may be of a temporary nature as defined in facility policy, admission agreements and disclosure information.

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

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 3 sampled residents (#s 2 and 4) who were administered as-needed controlled medications. Findings include, but are not limited to: 1. Resident 4 was admitted to the facility in 08/2022 with diagnoses including Alzheimer's disease and anxiety. The resident had a physician order for lorazepam 0.5 mg by mouth every two hours as needed for anxiety or agitation. Resident 4's 09/01/24 through 09/23/24 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following: *Between 09/01/24 and 09/23/2024, there were five occasions when staff signed the medication out in the disposition log; however, the MAR lacked documentation the resident received the PRN medication. Comparison of the medication bottle to the disposition log, showed the amount of medication left was reflected accurately on the log. Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 1 (MCC ED/LPN), and Witness 1 (Consultant Operations Specialist) on 09/25/24. No additional information was provided. The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 and Witness 1 on 09/25/24. The findings were acknowledged. 2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/30/24 included the following orders: * Lorazepam 0.5mg tablet, give one tablet every two hours PRN for agitation or anxiety; and * Morphine 20 mg/ml, give .25 ml every hour PRN for pain or shortness of breath. The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/24 through 09/24/24 showed the following: * On 09/18/24, the PRN Morphine was recorded on the MAR but was not signed out on the disposition log; and * On 09/23/24, the PRN Lorazepam was signed out on the disposition log but not recorded on the MAR. Comparison of the medication bottles to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

1) Audit comparing medication administration record to controlled-substance log regarding Resident 2, and 4 correcting inconsistencies in record. 2) Every other week medtech meetings including re-education on controlled -substance documentation and process for addressing descrepancies. Daily audit of controlled-substance log with medication admininstration record for a week, then weekly for a month. If consistantly correct, audit will be done every other week then monthly. 3) Daily, weekly, monthly 4) Memory Care Executive Director, Community Nurse

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

OAR 411-054-0055 (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 the accuracy of MARs which included resident specific parameters and instructions for PRN medications, including instructions for when or how often to administer the prn medications for 3 of 4 sampled residents (#s 1, 2 and 3) whose MARs were reviewed. Findings include, but are not limited to: 1. Resident 3 was admitted to the facility in 03/2018 with diagnoses including dementia. The resident's 09/01/24 through 09/23/24 MARs were reviewed, and the following inaccuracies were identified: a. Multiple medications lacked direction on how often the PRN medications could be administered as follows: * Haloperidol as needed for agitation or nausea; * Nitroglycerin as needed for chest pain; and * Loperamide as needed for diarrhea. b. Multiple PRN pain medications lacked resident specific parameters as to order of administration as follows: * Acetaminophen 1000 mg every four hours as needed for pain or elevated temperature; * Acetaminophen 650 mg suppository every six hours as needed for pain or elevated temperature; and * Morphine Sulphate .25 ml as needed for pain or shortness of breath. The need to ensure residents' MARs had clear resident specific parameters and instruction to staff for administration of PRN medications was discussed with Staff 1 (MCC ED/LPN), and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings. 2. Resident 1 was admitted to the facility in 07/2024 with diagnoses including anxiety and Alzheimer’s disease. Observation of the resident between 09/23/24 and 09/25/24 showed the resident was unable to answer detailed questions. The resident required simple questions without multiple choices or answer options. When questioned by staff the resident would become very anxious. Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following: * PRN Tylenol and PRN Oxycodone were both prescribed for pain. The parameters indicated Tylenol PRN for pain rating of 0-4 and Oxycodone PRN for pain rating 5-10. Both medications were administered with documented pain ratings that did not meet the directed parameter. There were no other resident specific directions for staff on when to use the Tylenol vs. the Oxycodone if/when a pain scale rating could not be obtained from the resident or other times the parameters should be disregarded. * PRN Bisacodyl Suppository ordered for constipation. There were no resident specific directions for staff on when to start use. The need to ensure medication administration records were complete and resident specific parameters were reflected was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings. 3. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia. Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following: * PRN Morphine and PRN Tylenol were both prescribed for pain. There were no parameters in place to direct staff which medication to treat with first. * PRN Bisacodyl Suppository ordered for constipation. There were no resident specific directions for staff on when to start use. The need to ensure medication administration records were complete and resident specific parameters were reflected was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings.

1) Nurse reviewed and updated resident 1, 2, and 3 medication administration records including as needed parameters and indication of use. 2) Complete Pharmacy audit of all Resident medication administration records scheduled for November. Clinical meeting 5 days a week including medication variances, new medications review for input of Resident specific parameters and/or need for provider clarification. Pharmacy to complete quarterly audits. Minimum 20 hours of Registered Nurse in Community. 3) Daily, weekly, monthly, quarterly 4) Memory Care Executive Director

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

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

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 4 sampled resident (#s 1, 2 and 3) who were prescribed PRN medications to address behaviors. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in 07/2024 with diagnose including anxiety and Alzheimer’s disease. Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following: * Lorazepam 0.5 mg tablet, give one tablet every two hours PRN for anxiety or agitation; and * Haloperidol 2 mg/ml, administer 0.50 ml every two hours PRN for agitation, anxiety, nausea, or vomiting. The Haloperidol started on 09/20/24 had no direction for staff when to use the Haloperidol vs. the Lorazepam. There was no indication how long after Lorazepam administration the Haloperidol should be given. The Lorazepam PRN dose was administered thirteen times, and the Haloperidol was administered six times between 09/18/24 and 09/24/24. The doses of Lorazepam and Haloperidol were administered between thirty-seven minutes and two hours apart depending on the specific administration date and time. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress or agitation. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and when to administer consecutive doses was discussed with Staff 1 (MCC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in 08/2016 with diagnoses including dementia. Review of the resident's 06/24/24 through 09/24/24 progress notes, physician communications and the 09/01/24 through 09/24/24 MARs showed the following: * Lorazepam 0.5 mg tablet, give one tablet every two hours PRN for anxiety or agitation; and * Haloperidol 2 mg/ml, administer 0.25 ml every two hours PRN for agitation, anxiety, nausea, or vomiting. The Lorazepam was administered six times and the Haloperidol two times between 09/01/24 and 09/24/24. There was no resident specific direction for staff to indicate which medication should be given first or second and when. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, distress, or agitation. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and when to give specific medications das discussed with Staff 1 (MC ED/LPN), Staff 2 (RCC) and Witness 1 (Consultant Operations Specialist) on 09/25/24. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 03/2018 with diagnoses including dementia, depression, and anxiety. The resident's 09/01/24 through 09/23/24 MAR and prescriber orders were reviewed. Resident 3 had the following physician orders for PRN psychotropic medications on the MAR: * Lorazepam, 0.5 mg tab every two hours as needed for anxiety; and * Haloperidol 1mg tab as needed for agitation. The MAR indicated the resident received the PRN lorazepam on 09/02/24. The resident's record lacked documented evidence non-pharmacological interventions were attempted and documented as ineffective prior to administering the PRN medication. During an interview, Staff 11 (MT) verified there was no documented evidence non-pharmacological interventions were listed on the MAR or had been attempted and documented as ineffective prior to administering the PRN lorazepam. The need to ensure non-pharmacological interventions were documented as attempted with ineffective results prior to the administration of PRN psychotropics was reviewed on 09/25/24 with Staff 1 (MC ED/LPN) and Witness 1 (Consultant Operations Specialist). The findings were acknowledged.

1) Nurse reviewed and updated current as needed psychotropic medications for Resident specific symptoms and non-pharmacological interventions. 2) Complete Pharmacy audit of all Resident medication administration records scheduled for first week of November. Pharmacy to complete quarterly audits. Clinical meeting 5 days a week including new medications as part of review for input of Resident specific parameters and/or need for Provider clarification. Minimum 20 hours of Registered Nurse in Community. 3) Daily, weekly, monthly, quarterly 4) Memory Care Executive Director

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

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff "Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) 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."

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly hired direct care staff (#s 12, 13 and 18) had documented evidence of training in First Aid and abdominal thrust within 30 days of hire. Findings include, but are not limited to: Staff training records were reviewed on 09/24/24 with Staff 20 (Business Office Manager). Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired on 06/11/24, and Staff 18 (MA), hired 08/07/24, lacked documented evidence they had completed First Aid and abdominal thrust training within 30 days of hire. The need to ensure staff completed the required training within 30 days of hire was reviewed with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings.

1) Staff 12, 13, and 18 will have documented first aid and abdominal thrust education. 2) Business office manager will track training for all hired employees to include pre-servie, 30-day, and annual training. Weekly audits and follow up with staff until all training is in compliance. Then monthly audits and follow up. 3) Weekly, Monthly 4) Memory Care Executive Director, Business office Manger

OAR 411-054-0070 (6)(9) Training within 30 days: Direct Care Staff "Prior to providing care to residents, all direct care staff must complete an approved pre-service dementia training. (6) 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."

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

Based on observation and interview, it was determined the facility failed to ensure residents rights of privacy in his or her own unit. Findings include, but are not limited to: During an interview on 09/25/24 with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) it was reported that all shared resident bathroom doors were not lockable for resident privacy. The need to ensure residents' rights of privacy in his or her own unit was discussed with Staff 1 and Staff 2 on 09/25/24. They acknowledged the findings.

1) Request for bid/estimate for installation from Contract Interiors 9/25/24. Once bid accepted, order will be placed. Once received all new locks/latches will be installed. 2) Installation upon receipt of supplies with staff training regarding the new door locks on bathrooms for Memory Care rooms/restrooms. 3) Daily Community walk throughs by Memory Care Executive Director and Environmental Services Director. 4) Memory Care Executive Director, Environmental Services Director

OAR411-004-0020(2)(d) Individual Privacy: Own Unit (2) Provider owned, controlled, or operated residential settings must have all of the following qualities: (d) Each individual has privacy in his or her own unit.

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

Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C372.

Refer to C372

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

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 newly-hired staff (#s 12, 13, and 18) completed all required pre-service orientation and dementia training topics; 4 of 4 staff (#s 8, 12, 13 and 18) demonstrated competency in all assigned job duties within 30 days of hire; a system to ensure long term staff completed the required number of annual in-service training hours, including the annual infectious disease training, and at least six hours of training on dementia care; and 2 of 2 long term non-care staff (#s 6 and 10) completed annual infectious disease training. Findings include, but are not limited to: Staff training records were reviewed with Staff 20 (Business Office Manager) on 09/24/24. The following was identified: 1. There was no documented evidence Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired 06/11/24, and Staff 18 (MT), hired 08/07/24, completed one or more of the following pre-service orientation and dementia training topics: * Infectious Disease Prevention; * Approved Home and Community Based Care course; * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * How to recognize behaviors that indicate a change in the resident’s condition and report behaviors that require ongoing assessment; and * Use of supportive devices with restraining qualities in memory care communities. 2. There was no documented evidence Staff 8 (MT), hired 07/20/24, Staff 12 (CG), hired 05/09/24, Staff 13 (CG), hired 06/11/24, and Staff 18 (MT), hired 08/07/24 demonstrated competency in one or more of the following areas within 30 days of hire: * Role of service plans in providing individualized care; * Providing assistance with ADLs; * Changes associated with normal aging; * Identification, documentation and reporting of changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * Medication and treatment administration training for Staff 8 and 18. 3. During the staff training review, Staff 20 was unable to explain or show documented evidence the facility had a system in place to ensure the required number of annual in-service training hours, including annual infectious disease training and at least six hours of training related to dementia care was completed. 4. There was no documented evidence Staff 6 (Housekeeper), hired 12/30/23, and Staff 10 (Lifestyle Assistant), hired 12/30/23, completed the required infectious disease training. The need to ensure the required pre-service and annual training was completed by staff as required, as well as the need to ensure direct care staff demonstrated competency in all assigned duties within 30 days of hire, was discussed with Staff 1 (MCC ED/LPN) and Witness 1 (Consultant Operations Specialist) on 09/25/24. They acknowledged the findings.

1) Staff 6, 10, 12, 13, 18 to complete all pre-service training including: infectious disease prevention, home and community based care course, and dementia training. Staff 8, 12, 13, 18 to complete all training required within 30 days of hire including: role of service plans, providing assistance with activities of daily living, changes associated with normal aging, identification, documentation and reporting of changes of condition, conditions that require assessment, treatment, observation and reporting, and medication, and treatment administration for staff 8 and 18. System will be in place to track annual in-service training including annual infectious disease and six hours of dementia care trainig. 2) Development of a training tracking system to include all current and any future employees. The tracking system will contain all required training and completion dates, staff names, and hire dates. 3) Once implemented the system will be audited weekly and then monthly once compliance is maintained. 4) Memory Care Executive Director, Business Office Manager.

OAR 411-057-0155(1-6) Staff Training Requirements (1) A memory care community must ensure staff who provide support to residents with dementia have a basic understanding and fundamental knowledge of the residents' emotional and unique health care needs prior to providing services to residents. The training requirements for staff who work in memory care communities are described in the following sections. (2) ALL STAFF TRAINING REQUIREMENTS. All staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete the following: (a) Orientation as required in OAR 411-054-0070(3) before performing any job duties. (b) Pre-service dementia care training as required before independently providing personal care or other services. The dementia care training must address these topics: (A) Education on the dementia disease process, including the progression of the disease, memory loss and psychiatric and behavioral symptoms. (B) 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 when responding to distressful behavioral symptoms. (C) Strategies for addressing social needs of persons with dementia and engaging them with meaningful activities; (D) Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: (i) Identify and address pain; (ii) Provide food and fluid; (iii) Prevent wandering and elopement; (iv) Use a person-centered approach. (c) Additional pre-service training topics that must be completed before independently providing personal care to residents: (A) Environmental factors that are important to resident ' s well-being (e.g. noise, staff interactions, lighting, room temperature, etc.); (B) Family support and the role the family may have in the care of the resident; (C) How to recognize behaviors that indicate a change in the resident ' s condition and report behaviors that require on-going assessment. (3) DIRECT CARE STAFF TRAINING REQUIREMENTS. Direct care staff must be directly supervised by a qualified staff person until they have successfully demonstrated satisfactory performance in any task assigned in the provision of individualized resident services. In addition to training required for all staff as described in paragraph (2): (a) Before independently providing personal care or other services to residents, direct care staff must complete training on: (A) How to provide personal care to a resident with dementia, including an orientation to the resident and the resident ' s service plan, as required in OAR 411-054-0070(4). (B) The use of supportive devices with restraining qualities in memory care communities. (b) Within 30 days after hire, direct care staff must complete training as outlined in OAR 411-054-0070(5). (c) Direct care staff who work in memory care communities licensed as residential care facilities or assisted living facilities must complete a total of 16 hours of in-service training annually. The six hours of annual dementia care training required pursuant to OAR 411-054-0070(6) may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (4) NURSING FACILITY STAFF. Staff who work in memory care communities licensed as nursing facilities must complete the following: (a) Orientation as outlined in OAR 411-086-0310, 42 CFR ? 483.95 (F 943). (b) Pre-service dementia care training as outlined in paragraphs (2)(b) and (c) and paragraph (3)(a) of this section. (c) A total of 16 hours of annual in-service training must be completed by direct care staff only. Four of the 16 hours must be dementia care training and may be included in the 16 hours of in-service training. Annual in-service hours required of each staff are due by the anniversary date of that person ' s hire. All completed trainings must be documented by the facility. (5) Persons providing or overseeing the training of staff must have experience and knowledge in the care of individuals with dementia. (6) The memory care community must have a method for determining and documenting each staff person ' s competency of training in accordance with the licensing rules. All training must be documented and available to the Department upon request.

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

Based on observation, interview, and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C270, C280, C302, C310 and C330.

Refer to C270, C280, C302, C310, C330

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

Based on observation and interview, it was determined the facility failed to maintain the kitchen and memory care kitchenette 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:   Observation of the main kitchen and memory care kitchenette were conducted on 11/14/23 from 10:10 am through 2:40 pm. The following was identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Walls throughout kitchen; * Flooring (near, under, and around large equipment); * Top of ice machine; * Top of juice machine; * Top of refrigerator; * Top of dishware machine; * Walk-in cooler floor; * Standing water in the walk-in cooler; * Walk-in cooling fan and ceiling; * Freezer floor; * Food trap under dishware washer; * Grease bucket; * Ceiling, ceiling vents, light fixtures; * Fire sprinklers; * Walkie Talkies and bases; * Meat slicer; * Wall behind meat slicer; * Industrial can opener; * Industrial mixer; * Wall behind industrial mixer; * Wall behind ware washing area; * Wall behind food prep area; * Walls and wall fixtures; * Food Ninja blender base; * Corners and edges of steam table line; * Corners and edges of deli cooler top; * Steam table hot water holders; * Electrical outlet behind meat slicer with black mold-like substance outlining plate; * Interior of oven; * Exterior of stove; * Interior and exterior of toaster; * Interior and exterior of hot plate holder; * Flat top grill and siding; * Interior of soup warmer; * Utility carts; * Interior and exterior of hot food cart; * Knife holder; * Interior and exterior of microwave; * Metal shelving in walk in cooler; * Interior and exterior of MCC oven; and * Interior of MCC kitchenette drawers and cupboards.   b. The following areas were found in need of repair:   * Dish machine with heavy mineral build-up in need of descaling; * Handwashing sink (left of juice dispenser) drainage was slow and without paper towels; * Stove knobs and handles cracked; * Several cooking utensils were observed to have integrity concerns (example: parts of utensils melted); * Thermometer on server refrigerator gauging incorrect temperatures. Gauge read 50 degrees F, Digital thermometer and food items read 40 degrees F; * Caulking behind dish pit area with dark mold-like substance; * MCC oven stove top cracked; * Food warming cart with multiple holes/cracks; and * Multiple cutting boards found heavily stained/scored. c. Poor infection control practices observed, but not limited to: * Ice machine had pink and black mold-like residue on inside of machine; * While prepping salads and sandwiches, same cutting board was used for multiple foods (lunch meat, cheese, bread, tomato); * When plating meals, cooks touched ready-to-eat food items with potentially contaminated gloves and did not use tongs for bread products; * On several occasions, thermometer was not disinfected properly between use; * Thawing protein in walk-in fridge with chicken above other proteins; * Sausage and bacon from breakfast service out for over four hours, sausage tempted at 79 degrees F. Staff planned on using for lunch service (e.g., BLTs, etc.); * Poor hand sanitizing practice between food handling; * Poor gloving practice between food handling; * Dry towels stored outside of sanitizer throughout kitchen (appeared to be for sanitizing buckets); * Open and exposed coffee filters; * Unlabeled product in walk-in cooler; * Uncovered product in walk-in cooler; * Uncovered ice cream stored in small freezer; * Unlabeled, undated food product in small freezer; * Facility's eggs were unpasteurized. Staff 2 confirmed facility makes eggs to order each morning including soft/under-cooked versions (over easy, over medium, poached); * Staff had open beverages located throughout kitchen; * Employee jacket on top of dish ware rack; * Cutting board not sanitized between uses; * Multiple kitchen staff preparing food without facial hair restraints; * Sanitizer bucket not at proper concentration for surface sanitation, and staff not changing every two hours as recommended; * Scoop observed to be stored in bulk food/beverage containers; * Small diameter thermometer probe was not observed in MCC kitchenette; * MCC care staff observed providing dietary services without the use of aprons; and * MCC care staff not checking temperatures of reheated food for residents to ensure safety. d. During Person-in-Charge (PIC) interview, Staff 2 (Executive Chef) struggled to verbally demonstrate adequate knowledge in storing of protein products to prevent cross contamination, proper cooling methods, three sink method for sanitization, time frames to change surface sanitizers, and proper reheat food temperature requirements. Staff 2 acknowledged she did not have any additional food service training/education beyond her food handler's card and her experience in other food establishments, including long term care facilities and restaurants. At approximately 2:20 - 2:40 pm, surveyors reviewed above areas with Staff 1 (Executive Director) and Staff 2 (Executive Chef). who acknowledged the identified areas.

In response to the memory care kitchenette area : A. Deep clean of entire area will be completed prior to compliance date . B. New oven and Food warming cart have been ordered to replace current appliances. C. Inservices will be completed by all staff by compliance date that addresses the following: Infection control practices,  thermometer probe uses/disinfecting. This will be corrected to prevent future violation by ensuring kitchennette is deep cleaned once a month and as needed . As well as continued supervision by Memory Care Director that this is followed. Monthly and as needed cleaning, ongoing training with current and new employees The Memory Care Director will be responsible for assigning such tasks to employees and ensuring it is done appropriately as well as continued In-services throughout year.

Based on observation, record review and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C240.

Please refer to C240

The findings of the kitchen inspection, conducted 11/14/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 11/14/23, conducted 02/29/24, 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 interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. Findings include, but are not limited to: Resident 1 was admitted to the facility in January of 2023. The following required elements were either incomplete or were not included on the evaluation form: * Mental health issues, including: a) Presence of depression, thought disorders, behavioral or mood problems; b) History of treatment; c) Effective non-drug interventions; * Personality, including how the person copes with change or challenging situations; and * Recent losses. On 05/03/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff 1 (Memory Care Director) and Staff 3 (LPN). They acknowledged the findings.

An audit will be completed by Memory Care Administrator  for each resident in memory care to ensure each assessment is complete with all the required elements as noted in OAR 411-054-0034 Upon initial evaluation MC Administrator or LN will use the updated Evaluation form that addresses all the required elements noted in the CBC guide. Memory Care Administrator  and LN will be responsible in ensuring the above is completed and followed.

Based on interview and record review, it was determined the facility failed to ensure initial move-in evaluations included all required elements for 1 of 1 sampled resident (#1) whose move-in evaluation was reviewed. This is a repeat citation. Findings include, but are not limited to: Resident 1 was admitted to the MCC facility in 07/2023. The following required elements were either incomplete or were not included on the evaluation form: * Cognition, including decision making abilities; * Activities of daily living including dental status; * Fluid preferences; and * History of dehydration On 07/27/23, the need to ensure the initial move-in evaluation contained all required elements was discussed with Staff (10) and Staff 3 (LPN). They acknowledged the findings.

The Offline Evaluation tool has been completely revised to update and include all elements required as noted in Re- Survey. The Updated Initial Evaluation will be used with any potential admissions prior to move in date. The Memory Care Administrator will be responsible in monitoring the accurate form is utilized and completed

Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. Findings included, but are not limited to: Record review on 05/02/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 04/01/23 to 05/03/23 revealed the scheduled staffing plan was not reflective of the ABST. In an interview on 05/02/23 with Staff 1 (Memory Care Director) and Staff 10 (ALF Executive Director) it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. The need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 1 and Staff 10 on 05/03/23. They acknowledged the findings.

This community shall utilize the acuity based staffing tool (ABST) to determine appropriate staffing for the community as noted in OAR 411-054-0037. The community will fully implement the ABST selected and complete an ABST assessment for each resident. The community will update and utilize the ABST tool to develop and routinely update the communities staffing plan to convert evaluated care needs of residents into staff hours to generate a community staffing plan. Memory Care Administrator will be complete and monitor / update  for accuracy weekly and as needed with any care changes.

Based on interview and record review, the facility failed to use the results of an Acuity-Based Staffing Tool (ABST) to develop and routinely update the facility's staffing plan. This is a repeat citation. Findings included, but are not limited to: Record review on 07/27/23 of the posted staffing plan, the facility's ABST, and the staffing schedule for 07/02/23 to 07/27/23 revealed the scheduled staffing plan was not reflective of the ABST. In an interview on 07/27/23 with Staff 10 (ALF Executive Director), it was determined the facility had not been scheduling the number of direct care staff as determined by the ABST. On 07/27/23 the need to ensure the facility followed the staffing plan generated by the ABST was discussed with Staff 2 (Health Services Director/RN), Staff 3 (Medication Licensed Nurse), and Staff 10. They acknowledged the findings.

The Community will utilize the ABST tool to determine time to meet staff levels and develop a staffing plan to specify the total number of weekly minutes required to meet the 24 HR scheduled and unscheduled needs of residents. This will be evaluated when there is a change in Level of care and/ or new admission. ABST numbers will be printed daily for review during normal business days. This Administrator will report to Kelsie Norton, Corrective Action Coordinator Bi- Monthly to address areas of noted concern, including but not limited to progress of implementation of ABST, barriers , proposed remediation of barriers and timelines for completion. The Memory Care Administrator is responsible to monitor and complete this Plan of Correctio

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and documented in accordance with Oregon Fire Code (OFC), and fire and life safety instruction to staff was provided and documented on alternate months. Findings include, but are not limited to: Review of fire drill and fire and life safety records for 11/01/22 through 05/01/23 identified the following: 1. The facility had not documented the following areas related to fire drills conducted: * Escape route used; * Problems encountered; * Comments relating to residents who resisted or failed to participate in the drills; * Evacuation time period needed; * Evidence alternate routes were used; and * Number of occupants evacuated. 2. In an interview conducted 05/02/23 at 1:30 pm with Staff 8 (CG) and Staff 9 (CG), they were unable to clearly state where the designated point of safety was located. 3. The facility did not consistently conduct and document fire and life safety instruction for staff on alternate months. The need to ensure the facility conducted fire drills per the OFC and provided fire and life safety instruction to staff on alternate months was reviewed with Staff 1 (Memory Care Director) on 05/03/23. She acknowledged the findings.

The community will conduct fire drills and life safety training as required per OAR 411-054-0090 requirements. The community will conduct fire drills every other month and life safety training on alternate months with complete documentation as required. All staff in- service on fire drills and life safety will take place on 5/10/23. Memory care Administrator and ESD will be responsible to oversee and conduct fire drills and life safety trainings.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 361 and C 420.

Referral tag, refer to C361 and C420

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 361.

Please refer to C252 and C361

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to: C 252

Referral tag, refer to C252

Based on interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to: Refer to C 252.

Please refer to C252 and C361

Based on 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 C 252, C 361, Z 142, and Z 162.

Please refer to C252 and C361

The findings of the relicensure survey conducted 05/01/23 through 05/03/23 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, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the first revisit to the re-licensure survey of 05/03/23, conducted 07/27/23, 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 57 for Memory Care Communities. 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 05/03/23, conducted 10/13/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations.