Capital Manor Retirement Community

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

Based on observation, and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Facility did not provide accurate textures for residents requiring puree. Findings include, but are not limited to: Observations were made of the main kitchen, dry food and paper product storage area, memory care unit kitchenette, and the RCF unit dining room kitchenettes on 10/13/25, between 10:00 am and 2:00 pm. The following areas were identified: 1. Main kitchen area a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Wall above metal rack storing clean dishes; * Floor between wall and prep tables; * Floor under metal racks in dry storage; * Floor sink in janitor closet; * Top of hot food storage cart; * Industrial slicer; * Table holding slicer; * Bottom shelf of prep table holding slicer under rack storing cutting boards * Portable metal baker’s rack; * Convection ovens; * Range top; * Exterior of garbage cans; * Wall behind range/fryer/conventional oven; * Flooring between, under, behind equipment; * Interior of deli cooler; * Juice machine; * Fan cages, ceiling and light fixture of walk in cooler; * Drain under service line/steam table area; and * Ceiling tiles, vents, smoke detector in/near dishwashing room. b. The following areas needed were found needing repair; * Caulking around hand washing sink * Caulking around industrial ware washing machine c. Multiple cutting boards were found heavily scored, stained, and/or missing chunks, deep grooves, and needed to be replaced. d. Cook noted to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service. e. Multiple kitchen staff observed handling food or clean equipment without hair restraints. f. Multiple items potentially hazardous food items found without opened/prepared dates. g. Multiple food items were observed stored uncovered/protected from potential contamination in both walk in cooler and freezer. h. Food contact surfaces of commercial slicer and single service utensils were stored uncovered/protected from potential contamination. Multiple clean/sanitized dishes and food contact surfaces of equipment were not being stored inverted as required. i. Multiple staff drink containers were observed in food preparation and/or storage areas that were not of approved styles yielding potential contamination of lip contact surfaces. Staff drinks were observed stored with resident food items. j. Facility did not have a system to ensure cold food items were at proper temperatures prior to meal service. Facility served a variety of cold items each meal from their deli cooler (tuna salad, deli sandwiches, egg salad, fruit and or vegetable items, etc) and did not ensure the items were at 41 degrees or below when served. Staff 2 was interviewed and confirmed the facility was not checking cold food meal service items prior to service as they were assuming the temperatures were the same as the temperature of the cooler they were stored in. k. Facility had two residents identified as having puree textures as part of their diets. Observations during meal service found the textures to be served to those residents that was too thin as it flowed through the tines of the fork. This does not meet the criteria of puree. 2. Memory Care kitchenette. a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Interior of reach in refrigerator; * Countertop mixer; * Interior of oven; * Interior of bottom cabinet next to oven; * Interior of reach in drawers; and * Black utility carts. b) Food and/or beverage items found in the reach in refrigerator observed uncovered/protected from potential contamination 3. Dining room kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Interior of microwave * Interior of drawer storing clean towels * Exterior/top of small ice machine b. Reach in cooler and/or freezer door seals were observed damaged/cracked and in need of replacement. c. Containers of bulk food items were observed with spoons stored inside the container with the handle touching food items causing potential contamination of the food products. At approximately 1:45pm, the above findings were shared with the Staff 1, Staff 2, and Staff 3 (Director of Dining & Culinary Services), who acknowledged the areas in need of correction.

C0240: 1. a) Action has been taken by refining our cleaning focus to delegate who and when the above-mentioned discrepancies will be cleaned. All tasks will be done by AM or PM kitchen staff. This cleaning focus will be checked daily by leads or designee. Weekly, a checklist with all state required regulations will be used by managers or designee. See attached cleaning focus (1.0 and 1.2). b) Work orders and repairs are in progress. Monthly, a walk through will be done by a lead or designee. In the event repair is needed, said lead/designee will place a work order for that repair. c) New cutting boards have been ordered to comply with regulations. See invoice (1.3). During the monthly walk though done by a lead or designee, cutting boards will be checked to maintain regulations. See checklist (1.0) d) Training has been done on proper glove usage for RTE foods on 10/25/2025. See document (1.4). e) Hair restraint policy has been updated to meet regulations. See attached policy (1.5). f) All kitchen and dining staff have been informed and trained on proper item-dating procedures. This training took place on 10/25/2025. See attached document (1.4). g) Daily, a walk-through will be done by a lead or designee to ensure that all food items are properly stored and covered. See checklist (1.0). h) Training procedures has been conducted. A walk-through will be done by lead or designee to ensure dishes and equipment are stored properly. i) All staff have been informed on personal drink usage and storage. See document (1.4). j) A system has been put in place to ensure safe food temperatures before service. Before each meal, a lead or designee will check the temperatures of all above mentioned areas and food items. k) Training process is in place with RDN and CDM on proper food textures, including purees, consistent with IDDSI standards. This training will take place on 11/20/2025. See attached document (1.8). 2. a & b) Proper training has been conducted with all staff utilizing the Memory Care kitchenette. This training includes proper sanitation and cleaning. A walk-through will be done before and after each usage by a lead or designee to ensure that area has been cleaned properly and that expired food/drink items are thrown out. See document (1.6). 3. a) Weekly cleaning tasks have been updated to assure that above listed areas are meeting regulations. These tasks will be signed off by a lead or designee on the day assigned. See attached task sheet (1.7). b) Work orders have been submitted. Items are in the process of being replaced. Walk-throughs will be done to ensure equipment is up to standard. c) Staff have been informed about proper food storage and utensil usage. A daily walkthrough will be done to ensure food in stored properly. See attachment (1.4).

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 a clean and sanitary kitchen in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to: Observations of the kitchen on 12/18/25, from 10:15 am through approximately 1:00 pm, showed the following areas needed cleaning or repair: 1. Main kitchen area a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Floor between wall and prep tables; * Floor under metal racks in dry storage; * Industrial slicer; * Behind table holding slicer; * Convection ovens; * Wall behind range/fryer/conventional oven; * Flooring between, under, and behind equipment; * Interior of deli cooler; * Juice machine; * Drain under coffee service area; and * Ceiling tiles and smoke detector in/near dishwashing room. b. The following areas were found needing repair; * Multiple cutting boards were found heavily scored or deeply stained and needed to be replaced. c. Multiple kitchen staff observed handling food or clean equipment without facial hair restraints. d. Multiple items of potentially hazardous food items found without opened/prepared dates. e. Potentially hazardous food items were found past manufacturer’s use-by date. A container of salad dressing was noted three months past the open date. There was no manufacturer’s use-by date and no note of the facility’s desired use-by date. There was visible green and white velvety biological debris found growing near the lip and lid of the container. 2. Memory Care kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Countertop mixer; and * Interior of reach-in drawers. 3. Dining room kitchenette a) An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: * Coffee dripping from coffee machine on countertop into interior of drawer storing dry cereal packages. At approximately 12:30 pm, the above findings were reviewed with Staff 1 (Administrator), Staff 2 (Dining Services Manager), and Staff 3 (Dining and Culinary Director) who acknowledged the findings.

1. Main Kitchen Areas a) A compliance specialist role has been designated where the mentioned areas will be cleaned deeply and thoroughly on a weekly or bi-weekly basis. This role will audit, clean, and document work in these areas. Walk-throughs will be done by a lead daily to ensure these areas are thoroughly attended to. See document (1.1). Ceiling tiles and smoke detectors are currently on an 120 day schedule to be cleaned. In addition, Maintenance team will clean every 30 days. b) New cutting boards have been ordered. See invoice (1.2). Additionally, leads and Compliance Specialist will check the integrity of our cutting boards weekly to ensure that new ones are replaced when needed. c) Our hair restraint policy has been updated to better accommodate safe food handling practices. All employees are required to sign off on this updated policy. See document (1.3). d) Staff training is in progress on proper dating and shelf-life for proper food safety compliance. See document (1.4). Leads and Compliance Specialist will be responsible for checking food storage areas daily. which is posted in the walk-in dry storage, fridge, and freezer. e) As stated above, a document stating the shelf life of our products has been posted for staff easy access. All food storage areas will be thoroughly checked daily by a lead or Compliance Specialist to ensure no potentially hazardous items are kept. 2) a). Memory Care kitchenette Life Enrichment staff will be responsible for keeping the kitchenette clean since they use it the most. A checklist and sign off sheet has been created to give staff something to go by and help keep them accountable. They will be turning the sign off sheet to the Administrator This will be evaluated daily by using the check off list and will be audited weekly by the Administrator or designee . See document (1.5) 3. Dining Room Kitchenette a) Our system has been updated to ensure these areas get deep-cleaned weekly and checked by a lead or designee daily. In addition, all items previously stored in drawers beneath the coffee machine have been moved to other designated locations. Additionally, repairs are in progress (work order placed12/30/25) to improve the integrity of our drawers.

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.

142: 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.

Z142: The above information includes Memory Care.

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.

Z0142: All above corrections apply to Memory Care.

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 411-054-0105 (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 interview, observation and review of records, 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.

Refer Plan Of Correction to addendum C 240

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.

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).

C 240: C) Food must be prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules) related to minor cleaning and repair, equipment in good repair, hair restraints and apron use, and food storage.

Based on observation, interview, and record review, conducted during a site visit on 08/05/24, it was confirmed the facility failed to fully implement and update an Acuity Based Staffing Tool. Findings include, but are not limited to: In an interview on 08/05/24, Staff 1 (Administrator) stated the building consisted of an RCF with two floors named "Manor Care 1 and 2" and a memory care named "Manor Care West." A review of the facility's Posted Staffing Plan stated the following: * Manor Care * Day: seven caregivers, two med techs, and one restorative aide; * Evening: seven caregivers and two med techs; and * Night: four caregivers and one med tech, who was shared with the memory care. * Memory Care * Day: five caregivers, one med tech, and one restorative aide; * Evening: five caregivers and one med tech; and * Night: three caregivers and one med tech, who was shared with Manor Care. In an interview on 08/05/24, when asked how the facility determines the staffing plan, Staff 1 stated this was "the plan the facility has always had." A review of the facility's ABST showed 312 total care hours, requiring 41.6 staff members for day shift. A review of the posted staffing plan and staff schedule revealed the facility was not staffing to the plan required by the ABST. In an interview on 08/20/24, Witness 2 (ABST Corrective Action Coordinator) stated the facility's high frequency count, which generated abnormally high staffing hours, was due to counting single ADL tasks across multiple ADLs in the ABST. Interviews with residents did not reveal any missed needs. The findings were reviewed with and acknowledged by Staff 1, Staff 2 (Director of Nursing), Staff 9 (Facility Compliance Specialist), and Staff 10 (Executive Director). It was confirmed the facility failed to fully implement an Acuity Based Staffing Tool.

Based on observation, interview, and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner, in accordance with the Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to: Observations were made in the kitchen on 10/25/23, between 10:26 am and 1:15 pm, with facility staff. The following deficiencies were identified: a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and/or grease was visible on, underneath, or between the following: *Industrial and counter top can opener and housing; *Industrial mixer base and dough hook; *Convection oven; *Range top; *Grout behind dishwashing area; *Fans and ceiling in walk in cooler; *Handwashing sink near dishwashing area; and *Bottom two shelves of racks holding clean dishes. b. Heating and cooling system vents in the food prep and tray line areas, as well as in cold storage, had a build-up of visible dust. The ceiling and walls around the vents also had a visible build-up of dust, risking potential contamination of food. c. The coating on the blade of the large can opener was peeling off, leaving an uncleanable surface. The blade needed to be replaced. d. Multiple cutting boards and utility carts were found heavily scored, stained, and/or missing chunks, and needed to be replaced. e. In the dry storage area, multiple cans of food were observed dented/damaged. f. Multiple carts were observed lined up against the wall in a hallway near a dining room at 10:20 am. The carts held covered food and uncovered utensils and were accessible by anyone passing the area, exposing them to potential contamination. The Dining Services Manager reported there was a lack of space in the kitchen area for tray set up, so food delivery carts were kept in the hallway until service. g. Kitchen employee was observed to repeatedly handle RTE (ready to eat) food items with potentially contaminated gloves during tray line service. h. Memory care kitchenette reach in refrigerator was found to be at 49 degrees Fahrenheit. This was the units resident snack fridge. Review of documentation of temperature sheet revealed 10 times since 10/12/23 that the refrigerator temperatures were at higher than 41 degrees (42-48 degrees). Milk and condiments were observed stored in that refrigerator. Facility administrative staff verified they were not informed of any temperature concerns with that refrigerator. The findings were shared with the Staff 1 (Administrator) and Staff 2 (Dining Services Director) on 10/25/23 at 1:00 pm. They acknowledged the findings.

C240: a. Action has been taken by refining our cleaning focus to delegate who and when the above-mentioned discrepancies will be cleaned. All tasks will be done by AM and PM kitchen staff. This cleaning focus will be checked daily by leads or designee.Weekly, a checklist with all state required regulations will be used by managers or designee. See attached cleaning focus (1.1) and checklist (1.2). b. Maintenance will perform regular vent cleaning. A work order will reoccur on the first Monday of every month. The vents, walls, ceiling, and shelving will be checked for any buildup of dust. Wiping walls will be part of the cleaning focus. See attached cleaning focus (1.1). Weekly, a walkthrough performed by the leads or designee, will be performed. See checklist (1.2). c. A new blade and inner mechanisms have been ordered and sent for immediate repair. See invoice (1.3). A task on the cleaning focus will be delegated by a team lead or designee to clean can openers. See attached cleaning focus (1.1). During the weekly walkthrough done by managers or designee, the can opener will be monitored for food debris or rust build up. See checklist (1.2).

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.

e. A designated area has been made in the dry storage to place any dented/damaged cans away from non-damaged cans. A memo has been made and training have been put into place to ensure all staff are aware of regulations and how to handle damaged goods on 12/16/23.  Staff that actively put stock away have been trained by leads.During the weekly checklist done by the manager or designee (see 1.2), the dry storage will be monitored to ensure no damaged cans are mixed in with non-damaged cans. Immediate disposal will be taken if damaged cans have been found. See attached notice and training summary (1.6, 1.7) f. A new policy has been put into place to keep trays from potential contamination. All trays will be stacked and kept in the storage closet with no silverware until needed for tray service. We will no longer have trays set up and ready in the hallway. Moving forward, all food and utensil set up will be done in the kitchen 15 minutes before service starts in the dining room (7:15am, 11:15am, & 4:15pm). Silverware will be wrapped in the napkin to keep from exposure. Serving staff have been trained and a training meeting has been scheduled for 12/16/23. See attached training summary and tray notice (1.7, 1.8). g. Training has been scheduled to remind all kitchen staff about safe food handling 12/16/23. We have purchased smaller, individual utensils to use for line service to prevent any contamination of ready to eat foods when serving. See invoice and training summary (1.4, 1.7). h. Training has been scheduled on 12/16/23 to ensure staff are aware of safe refrigerator and freezer temperatures. Temp logs identify what safe temperatures are and to report to managers if temperatures are not safe. See training summary and temp logs (1.7, 1.9.) C999: (1) All staff have been informed about Noro Virus and the symptoms associated with the virus. A policy has been posted and communicated to maintain infection prevention. Staff are aware of what to do and to contact direct supervisors when symptoms occur to prevent infection. See policy (1.10). C370 A spreadsheet has been made to ensure that all staff have valid and up to date OR food handler's certificates. The dining service supervisor is to keep track of all food handler's certificates monthly to ensure compliance with regulations. See spreadsheet (1.11). Z142: The above information applies for memory care.

The findings of the kitchen inspection, conducted 10/25/23, 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 10/25/23, conducted 01/04/24, 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.

2. On 11/09/22 at approximately 7:30 am, the surveyor observed a caregiver provide incontinent care to Resident 2. During the process, Staff 17 (CG) removed the resident's soiled incontinent brief, which was saturated with urine, and tossed it on the floor near the garbage can. Staff 17 changed gloves after removing the brief. The resident was assisted from the toilet, bottom wiped and barrier cream applied all over the resident's bottom. Staff 17 did not change gloves prior to pulling up the residents brief and pants. This left large white sections of barrier cream along the waist band and back of the resident's pants. Staff 17 bagged up all soiled items, washed hands and wheeled the resident out of his/her room. When no attempt had been made to disinfect the floor prior to leaving the resident room, the surveyor asked the staff member to disinfect the floor where the brief had been. Approximately 15 minutes later housekeeping was observed in the resident's room. The need to ensure staff consistently used proper infection control and universal precautions when incontinent care was provided was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings. 3. Resident 1 was admitted to the facility in 07/2016 with diagnoses including dementia. Review of the current service plan, dated 08/18/22, as well as interviews with staff, revealed s/he required full assistance with all ADLs. On 11/08/22 care staff were observed providing incontinence care for the resident. Care staff removed the resident's soiled brief, provided perineal care, disposed of the brief, put on a clean brief, and transferred the resident to his/her wheelchair without changing gloves. After care staff removed their gloves, they did not perform hand hygiene. The need to follow proper infection control and hand hygiene procedures was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.

Based on observation and interview, 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: Observations were made during the survey to determine adherence to universal precautions for infection control. 1. On 11/09/22 at 11:10 am the surveyor obtained permission and observed Staff 12 (CG) provide toileting assistance to Resident 7. During the observation Staff 12 failed to change gloves after wiping urine from Resident 7's perineum. Staff 12 touched the resident's clothing and multiple areas on the resident's wheelchair while wearing the same soiled gloves. The need to ensure staff exercised universal precautions and infection control standards was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), and Staff 3 (Compliance Specialist) on 11/09/22. They acknowledged the findings.

Example 1) We will be providing standard precautions training for all staff in Manor and Memory Care. In addition, we will have standard precautions training every 6 months ongoing. All 3 Care Coordinators will audit and record 2 random caregivers per month to ensure staff consistently use proper infection control and universal precautions when incontinent care is provided. Care Coordinators will keep 2 year's worth of audits ongoing. New policy has been created to give step by step instruction on how to assist and care for a resident with incontinence while maintaining consistent standards of infection control In addition, Administrator or designee, DON or designee, and Care Coordinators will have a monthly audit meeting to ensure compliance   Example 2) We will be providing standard precautions training for all staff in Manor and Memory Care. In addition, we will have standard precautions training every 6 months ongoing with return demonstration. Also included in the training, the inappropriatness of tossing soiled incontinent products or any other soiled items on the floor. Also, if something does get on the floor, staff will be trained to immediatly clean up soiled area with a disposable wipe and then call housekeeping to sanitize the area before the resident goes back in the bathroom. All 3 Care Coordinators will audit and record 2 random caregivers per month to ensure staff consistently use proper infection control and universal precautions when incontinent care is provided. Care Coordinators will keep 2 years worth of audit records ongoing. A new policy has been created to give step by step instruction on how to assist and care for a resident with incontinence while maintaining consistent standards of infection control In addition, Administrator or designee, DON or designee, and Care Coordinators will have a monthly audit meeting to ensure compliance

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements and were completed prior to the resident being admitted to the facility for 1 of 2 sampled residents (#4). Findings include, but are not limited to: Resident 4 was admitted to the facility on 07/08/22. The resident's move-in evaluation was dated 06/08/22. The following elements were not addressed in the move-in evaluation: * Skin conditions; * Treatment needs; * Emergency evacuation ability; * Elopement risk or history; and * Environmental factors which impact the resident's behavior, including, but not limited to, noise, lighting, and room temperature. The need to address all elements of a move-in evaluation prior to a resident being admitted to the facility was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.

Example 1 and 2 1) Added to our admit checklist "evaluation and service plan are complete with proper dates". 2) Medical Records Clerk is the last person to sign off on the checklist and will ensure everything is correct. 3) The area needing correction will be evaluated with each new admit. 4) The Medical Records Clerk. We will train the Medical Records Clerk as to what she will need to be monitoring, ie: all sections are completed, to be determined is not an acceptable entry, eval and service plan are dated appropriately. 5) New admit service plans will be reviewed on the first business day following admission by the IDT to ensure all information and dates are reflective of residents needs. IDT consists of the Administrator, DON, Care Coordiantor's, Compliance Specialist, Lead Nurse, Lead Med Tech, Lead Caregivers, Support Services, Home Care Manager, Medical Records Clerk, Kitchen Manager, Staffing Coordinator, Chaplain. 6) All staff will be educated on the importance of reading and signing off on all ISP's.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and were followed by staff for 5 of 11 sampled residents (#s 1, 2, 3, 4 and 7) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 07/25/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Behaviors including disrobing; * Falls, frequent checks, tab alarm and low bed; * Supervision in the dining room; * Incontinent care and toileting assistance; and * One vs two person transfers and gait belt use. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in July 2022 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan, dated 08/12/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Behaviors including physical aggression towards staff; * Falls, frequent checks, motion alarm and bed height; * Incontinent care, toileting assistance and frequency of assistance; * Keeping the resident's door open; * Fluids within reach and refilled throughout day; * Activities and television use; * Staff assistance with bathing, toileting and dressing; and * One vs two person transfers and gait belt use. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings. 3. Resident 7 was admitted to the facility in October 2021 with diagnoses including Alzheimer's disease. Observations of the resident, interviews with staff and review of the service plan dated 09/05/22, showed the service plan was not reflective of the resident's current care needs in the following areas: * Level of required meal assistance; and * Refusal of gait belt use. The need to ensure service plans were reflective of resident care needs was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), and Staff 3 (Compliance Specialist) on 11/09/22. They acknowledged the findings. 4. Resident 1 was admitted to the facility in 07/2016, and Resident 3 was admitted in 05/2014, both with diagnoses including dementia. Current service plans and quarterly resident evaluations were reviewed, observations were made, and staff were interviewed. The following was identified: Information about the residents' food and beverage preferences and/or leisure activity interests were on the evaluation, but had not been included in the service plan. Staff 1 (Administrator) stated, in an interview on 11/09/22, caregiving staff do not have access to residents' evaluations, only to their service plans. The need to ensure information on the quarterly resident evaluation is included in the residents' service plans and available to caregiving staff was discussed with Staff 1, Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.

Example 1 and 2 1) ISP's were noted on resident #2 dated 8/25/22, 9/6/22, 9/8/22, and 9/29/22 that addressed all concerns noted except for behaviors including disrobing. 2) Task sheets created for care staff to have clear direction on care expectations. Staff will document daily on care provided. 3) Monthly audit and retain records for 2 years 4) Medical Records Clerk Example 3 1) To ensure the current care needs of the residents are reflective of the service plan, a Caregiver Observation Tool has been created to alert nurses of any changes, decline or improvement, in a timely manner. 2) Training of all care staff, housekeeping, and food service on the use of the Caregiver Observation Tool. 3) IDT will review within 72 hours to ensure appropriate interventions are in place. Monitoring to follow 4) DON or designee, and Administrator, or designee Example 4 1) Care Coordinators and Administrator or designee will audit all records to ensure that all information needed in the service plan has been included from the evaluation 2) Compliance Specialist to audit evaluations and service plans after each quarterly review or as needed. 3) Quarterly and as needed 4) Compliance Specialist

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 3 of 9 sampled residents (#s 2, 3 and 4) who experienced changes of condition. Resident 2 experienced repeated falls with significant injury, and Resident 3 experienced ongoing weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. Interviews with staff and review of the resident's 07/25/22 service plan, 08/01/22 through 11/07/22 progress notes, incident investigations and physician communications were completed. Observations between 11/07/22 and 11/09/22 revealed the resident had a tab alarm in place while in bed and in the wheelchair. The resident was noted to pull on the clip and move the alarm when s/he was in bed. A fall mat was in place when the resident was in bed. The resident's bed was intermittently in the lowest position. The resident was unable to move himself/herself from the bed to wheelchair or wheelchair to bed safely. The resident was observed to be weak and unable to stand securely with support during toileting assistance. The resident could not initiate care from staff, utilize the call light or understand his/her safety limitations. The dining room was inconsistently monitored by staff throughout the day and the resident's apartment door was frequently closed while the resident was in bed. a. The resident experienced multiple injury and non-injury falls as follows: * On 08/01/22, a note indicated the resident had a fall on 07/30/22, the resident was found on the floor with a skin tear noted. Intervention to implement was a tab alarm at all times. * On 08/13/22, the resident's tab alarm alerted staff who found the resident on the floor in his/her room with no clothing or brief on. No injury was noted. Intervention to be implemented was offer the resident to come to dining room when awake. * On 08/14/22, the resident was found on the floor in his/her room with no clothes or brief in place. The resident stated s/he tried to go to the bathroom. A skin tear was found on the resident's left elbow. Intervention implemented was to keep the resident in the dining room before, during and after meals. An X-ray was completed on 08/24/22 related to ongoing pain and transfer difficulties. The resident was found to have a pelvic fracture. * On 08/25/22, the resident's tab alarm sounded and the resident was found on the ground in the dining room with a skin injury to the right shin, area was noted as both an abrasion and a skin tear. Intervention implemented was not to leave the resident unattended after meals. * On 09/04/22, the resident's tab alarm sounded and the resident was found on the floor in his/her room in a pool of blood. The resident had a wound to the back of his/her head but extent of injury was not visible due to blood. The resident was transported to the emergency room for evaluation. The resident returned with staples to the back of his/her head. Intervention implemented was provide toileting assistance before putting the resident to bed. *  On 09/29/22 at 11:00 am, the resident was witnessed to stand, set off tab alarm, lose his/her balance and fall on his/her bottom. The investigation indicated the resident seemed to be worried about a bloody nose from earlier in the day and attempted to get something for his/her nose. No injury noted. Intervention to implement was noted if the resident's nose was bleeding then staff were to attempt to stop the bleed by pinching bridge of the nose and provide the resident a towel to catch the blood. * On 09/29/22 at 9:09 pm, the resident was found on the floor in the common area bathroom near the dining room. Tab alarm was not in place, resident stating in "agony," hip pain expressed repeatedly as well as bruising and swelling to the right hip. Intervention to implement was for staff to ensure the tab alarm was in place and attached between the resident's shoulder blades. The resident was transported to the emergency room for evaluation and admitted to the hospital with a fracture which required surgery. The resident returned on 10/10/22. *  On 10/23/22, the resident was found partially on the fall mat next to his/her bed. The resident's tab alarm was not sounding. The resident stated s/he was "trying to go pee." No injury was noted. Intervention to be implemented was to offer the resident frequent toileting after meals. There was no documentation to show ongoing evaluation of existing interventions, determination and implementation of any new interventions and monitoring of those interventions for effectiveness after each of the resident's falls. The investigations did not indicate what may have contributed to the falls, nor did they address interventions to prevent future occurrences. Resident 1 had repeated falls with and without injury, including two fractures and a laceration to the head, without sufficient evaluation, monitoring and intervention by the facility to prevent further injuries and falls. b. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Bruising, skin tears and excoriation; * New medications and medication changes; * Falls: injury and non injury; * Weights, snacks and fluid intake; * Behaviors including disrobing and brief removal; * Bloody nose; and * Sutures. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings. 2.  Resident 4 was admitted to the facility in July 2022 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the resident's 08/12/22 service plan, 08/02/22 through 11/04/22 progress notes, incident investigations and physician communications were completed. The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas: * Falls with and without injury and safety interventions; * Behaviors including urinating on the floor, refusal of care and striking out at staff; * Skin tears, edema and pannus rash; * New medications and medication changes. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression. The resident's clinical record was reviewed, including the service plan, resident evaluations, incident reports, interim service plans (ISPs), progress notes, MARs, and weight records, and staff were interviewed. Weight records from 05/2022 through 11/2022 indicated the resident weighed: * 05/01/22: 149.2 lbs.; * 08/06/22: 137.6 lbs.; and * 11/01/22: 108.4 lbs. The resident lost 11.6 pounds from 05/01/22 to 08/06/22, which was a 7.7% loss of his/her total body weight. This represented a significant weight loss in 30 days and constituted a significant change of condition. The resident lost 29.2 pounds between  08/06/22 and 11/01/22, or 21.2% of his/her total body weight. This was a severe weight loss in 90 days and constituted a significant change of condition. A 40.8 lb. loss in six months, from 05/01/22 to 11/08/22, or 27.3% of his/her total body weight, represented a severe weight loss, which was also a significant change of condition. There was no documented evidence the facility RN was notified of the resident's weight loss; actions or interventions were determined, communicated to staff on all shifts, and implemented; or interventions were monitored for effectiveness. The resident continued to lose weight. Observations from 11/07/22 through 11/09/22 revealed Resident 4 was asleep in bed while the surveyor was in the facility. S/he was not observed to eat or drink anything. Staff indicated s/he had been admitted to hospice on 11/05/22. In an interview on 11/09/22, Staff 2 (Director of Nursing) stated the documented weights were incorrect because staff had not been weighing the resident correctly. Staff 2 was unable to provide any documentation indicating the resident's documented weights were incorrect or staff had not weighed him/her according to the facility's procedure. The need to ensure all changes of condition were evaluated and referred to the RN if indicated; had actions and/or interventions developed, implemented, and communicated to staff on all shifts; and interventions were monitored for effectiveness was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings. No additional information was provided.

Example 1 and 2 1) Book devloped specifically for ISP's. IDT will audit  ISP book weekly to ensure that short term changes of condititon and interventions are documented and monitored to resolution. Task sheets will be created for care staff to have clear direction on care expectations Staff will document daily on care provided. 2) Weekly audit of ISP book by IDT. Medical Records Clerk will audit flow sheet monthly. 3) Weekly and Monthly 4) IDT and Medical Records Clerk Example 3 1) Systems for monitoring weights to include identification of residents who have weight variences, and weighed with a specific device. Training with all care staff regarding how to get a proper weight on a resident who uses a wheelchair. Documentation form created to included a column that is specifically for wheelchair weight. DON or designee will review weights after the 10th of the month to monitor for weight variences. DON or designee will also make sure to receive information regarding changes, interventions, and updates through the IDT meetings. 2) Weight audits will be reviewed by IDT 3) Once a week 4 IDT

2. Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression. The resident's clinical record was reviewed, including the service plan, resident evaluation, incident reports, interim service plans (ISPs), progress notes, MARs, physician orders, hospice notes, and weight records, and staff were interviewed. a. Weight records from 05/2022 through 11/2022 indicated the resident weighed: * 05/01/22: 149.2 lbs.; * 08/06/22: 137.6 lbs.; and * 11/01/22: 108.4 lbs. The resident lost 11.6 pounds from 05/01/22 to 08/06/22, which was a 7.7% loss of his/her total body weight. This represented a significant weight loss in 30 days and constituted a significant change of condition. The resident lost 29.2 pounds between  08/06/22 and 11/01/22, or 21.2% of his/her total body weight. This was a severe weight loss in 90 days and constituted a significant change of condition. Between 05/01/22 and 11/01/22, the resident lost a total of 40.8 pounds, or 27.3% of his/her total body weight. This represented a severe weight loss, which was also a significant change of condition. There was no documented evidence the facility RN had completed a significant change of condition assessment for the resident's severe, ongoing weight loss. b. During the acuity interview on 11/07/22, Resident 3 was identified as having been admitted to hospice "within the last few days." A progress note dated 10/21/22 indicated the resident's physician had referred him/her to hospice. Progress notes from 10/21/22 through 11/04/22 revealed nursing staff were communicating with hospice related to when the resident would be admitted. There was no documented evidence the facility RN had completed a significant change of condition assessment when the resident was admitted to hospice on 11/05/22. In an interview on 11/09/22, Staff 2 (Director of Nursing) stated the resident was "put on a significant change of condition," but she had not completed a significant change of condition assessment. The need to ensure an RN assessment was completed in a timely manner for all significant changes of condition was discussed with Staff 1 (Administrator), Staff 2, Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings. No additional information was provided.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 2 of 6 sampled residents (#s 2 and 3) who experienced significant changes of condition related to weight loss. Residents 2 and 3 experienced severe weight loss. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in October 2018 with diagnoses including dementia. The resident's 07/25/22 service plan, 08/01/22 through 11/07/22 progress notes, investigations and physician communications were reviewed and staff interviews were conducted. In an interview on 11/09/22, Staff 3 (Compliance Specialist) indicated monthly weights were to be completed by the 5th of each month and re-weights done by the 10th. a. Weight records documented from May 2022 through November 2022 indicated the resident experienced a 10.6 pound weight loss from June to September 2022. This constituted a 10.01% severe weight loss in three months. The resident experienced a fall on 09/29/22 and sustained a head injury and a fracture. The resident was hospitalized from 09/30/22 to 10/10/22 and surgery was completed. The resident had no documented weight in October upon his/her return to the facility. The resident's weight in November 2022 was documented as 97.8 pounds. The resident's intake varied and s/he received a regular texture diet. The resident required full assistance from staff for his/her ADLs but could feed himself/herself once meal items were delivered. Multiple observations of the resident between 11/07/22 and 11/09/22 showed the resident was independent with his/her meal once it was delivered. The resident ate in the dining room, received cut up foods and 2-3 cups of fluid, usually a juice, coffee and/or water. The resident ate 25-100% of the meals observed. The resident was observed both to be alert and eating well and pushing plate away and taking no bites. Observations of the resident with no meal intake showed staff sat with the resident, fed him/her a bite, left the table and did not return. The resident did not initiate any further bites on his/her own and the plate was cleared approximately 20 minutes later. Additional observations showed the resident accepted fluids when offered throughout the day, if up in the dining room. The resident was not observed to receive a snack when in the dining room or offers/assistance with fluids when in his/her room. The resident did require intermittent cueing to continue with his/her meal and fluids. The resident was not offered additional helpings of any of the meal items when his/her meal was fully eaten. The resident spent 20-40 minutes at the table eating, which varied by the time of day. In interviews on 11/07/22, Staff 8, Staff 13 and Staff 32 (CGs) indicated the resident's intake was fair to good. The staff indicated the resident was able to eat on his/her own and enjoyed coffee. The resident required reminders to continue to eat and drink. b. The resident experienced a fall on 08/14/22 with a skin tear. On 08/16/22 progress notes indicated the resident had increased hip pain, significantly decreased mobility, pain with transfers and decreased physical therapy participation. A progress note dated 08/18/22 indicated the resident's physician was called for follow up on fax of 08/16/22 regarding hip pain. A message was left for the physician requesting an X-ray of the resident's left hip. A progress note dated 08/19/22 indicated family was contacted to inform them a request was made for an X-ray, but the physician had not responded yet. The family was advised they could take the resident to urgent care. The family indicated they would contact the resident's physician first before considering transport to urgent care. A progress note dated 08/23/22 indicated the resident's family called the facility for an update on the X-ray request related to the resident's problems with transfers. The physicians office was contacted again and order obtained for an X-ray to be completed on 08/24/22. A progress note dated 08/24/22 indicated staff were to keep the resident in bed and as comfortable as possible, non-ambulatory and non-weight bearing. Transfers were to be completed with a mechanical lift. A progress note dated 08/25/22 completed by Staff 2 (Director of Nursing Services), indicated the resident recently had a couple of falls and a recent X-ray showing a pelvic fracture. The physician indicated the resident's fracture was a common one and s/he could be weight-bearing as tolerated. The resident would continue to work with PT and appeared to be in no pain. The facility failed to ensure a thorough RN assessment was completed for the fracture which documented findings, resident status and interventions made as a result of the assessment. The resident continued to experience falls with a head laceration and an additional fracture. 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 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.

Example 1 and 2 1) Home Care RN will be utilized, in the absense of DON to ensure a thorough RN assessment will be completed with documented findings, resident status, and interventions made as a result of an RN assesment on a weekly basis. 2) We will have an RN available daily to complete SCOC assessment. 3) Weekly audit 4) Compliance Specialist

Based on and interview and record review, it was determined the facility failed to ensure it had a trained Infection Control Specialist as prescribed in OAR 411-054-0050 Infection Prevention and Control. Findings include, but are not limited to: In an interview on 11/09/22, Staff 1 (Administrator) reported Staff 27 (Environmental Services Director) was the facility's designated Infection Control Specialist. Review of Staff 27's infection control training revealed she had not completed the required specialized, Department-approved training in infection prevention and control protocols for a Residential Care Facility infection control specialist. The need to ensure the designated Infection Control Specialist completed all required training was reviewed with Staff 1 and Staff 27 on 11/10/22. They acknowledged training had not been completed as required.

1) Director of Environmental Services completed the required specialized, department approved training in infection prevention and control for a residential care facility infection control specialist while surveyors were still here. Completed on 11/9/22. 2) Any changes in personnel will be monitored and the Administrator or designee will ensure that the new employee has the training. 3) With new EVS Director or with changes by DHS 4) Administrator or designee

Based on interview, observation, and record review, it was determined the facility failed to ensure controlled substances were logged and administered accurately for 1 of 3 sampled residents (#3) whose PRN narcotics and psychotropic medications were reviewed. Findings include, but are not limited to: Resident 3 was admitted to the facility in 05/2014 with diagnoses including dementia, anxiety disorder, and depression. A review of the resident's clinical record, including the 10/01/22 through 11/07/22 MARs, physician orders, and the controlled substance disposition log, revealed the following: a. The resident had a physician's order for morphine (a narcotic) 20mg/ml sol 15 ml, take 0.25 ml (5 mg) by mouth every hour as needed for pain or shortness of breath. * Two entries in the controlled substance disposition log for PRN morphine were not listed on the MAR as having been administered to the resident: - 11/05/22 at 7:37 pm; and - 11/07/22 at 10:00 pm. * One administration of PRN morphine was listed on the MAR for 11/06/22 at 12:19 pm but was not listed in the controlled substance disposition log. b. Resident 3 had an order for Ativan (a psychotropic) 0.5 mg, take one tab (0.5 mg) "every two hours as needed for anxiety, restlessness, insomnia." * One administration of Ativan (for anxiety and agitation) was logged in the controlled substance disposition log, but not on the MAR: - 11/05/22 at 10:22 pm. The need for entries in the narcotic disposition log and entries on the MAR to correspond was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing), Staff 3 (Compliance Specialist), and Staff 5 (Memory Care Coordinator) on 11/09/22. They acknowledged the findings.

1) Lead Med Tech will audit all records to make sure we are in compliance. 2) Narcotic Weekly Audit Form created and Lead Med Tech will be auditing every week. 3) Weekly 4) DON or designee

Based on interview and record review, it was determined the facility failed to ensure specific reasons for use of PRN psychotropic medications were included on the MAR, and non-pharmacological interventions had been documented as attempted and ineffective prior to administration, for 1 of 1 sampled resident (#6) who were prescribed and were administered PRN psychotropic medications. Findings include, but are not limited to: Resident 6 was admitted to the facility in 08/2022 with diagnoses including anxiety. The resident's 10/01/22 through 11/07/22 MARs were reviewed, and the following deficiencies were identified: * PRN Ativan 0.5 mg (for anxiety) was administered on 8 occasions from 10/01/22 through 11/07/22. The facility failed to document non-pharmacological interventions as ineffective prior to administering the medication; and * PRN Haloperidol Lactate 2MG/ml (for hallucinations) failed to include non- pharmacological interventions for staff to attempt prior to administration of the medication and to specify how the resident exhibited signs and symptoms of hallucinations. On 11/09/22, the need to include resident-specific parameters on the MAR for PRN psychotropic medications and documented evidence of non-pharmacological interventions were attempted prior to administering psychotropic medications was discussed with Staff 1 (Administrator) and Staff 3 (Compliance Specialist). They acknowledged the findings.

1) All residents on antipsychotropic medications will be reviewed for resident specific parameters using the residents behavioral expressions of the diagnosis. Orders will be modified to include nonpharmcological interventions for prn's attempted and evaluated prior to administration. 2)Staff will be re-educated on documentation to include nonpharmacological interventions attemped prior to administration and the importance of documenting how the resident is exhibiting signs and symptoms and the effectiveness of the nonpharmacological intervention outcome. 3 and 4) The evaluation of charts will be weekly for 2 months and then monthly chart audits by Medical Records.

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 newly hired direct care staff (#s 9, 10, 20, 24 and 33), demonstrated satisfactory performance in all required areas within 30 days of hire. Findings include, but are not limited to: Training records were reviewed with Staff 28 (Staffing Development Coordinator) 11/07/22 through 11/09/22. The following deficiencies were identified: There was no documented evidence Staff 9 (CG), hired 09/14/22, Staff 10 (CG), hired 09/07/22, and Staff 33 (MT), hired 08/24/22, demonstrated competency in all required areas within 30 days of hire including: * Changes associated with normal aging; and * Abdominal thrust. There was no documented evidence Staff 20 (MCC) (CG), hired 05/18/22, and Staff 24 (MCC) (CG), hired 06/13/22, demonstrated competency in abdominal thrust within 30 days of hire. The need to ensure newly-hired direct care staff demonstrated satisfactory performance in all required areas within 30 days of hire was discussed with Staff 1 (Administrator), Staff 5 (Memory Care Coordinator) and Staff 28 on 11/09/22. They acknowledged the findings.

1) We have redone our entire onboarding process to include making sure that staff will have all pre-service training, all within 30 days of hire training, and this includes changes associated with normal aging and abdominal thrust return demonstration. 2) Policy and Procedure written to ensure that new staff will not be allowed on the floor until they have had CM orientation, Manor Care orientation, Caregiver 101 and Heartfelt Connections. Caregiver 101 and Heartfelt Connections have all the required pre-floor, pre-service, and within 30 days of hire. 3) Staffing Coordinator will audit entire hiring record to ensure record is complete and compliant. 4) Staffing Coordinator and Administrator or designee

Based on interview and record review, it was determined the facility failed to conduct fire drills according to the Oregon Fire Code (OFC). Findings include, but are not limited to: Fire and Life Safety records from 05/2022 through 11/2022 were reviewed on 11/08/22. The fire drill records did not include the following required information: * Escape route used; * Problems encountered, comments relating to residents who resisted or failed to participate in the drills; * Evacuation time-period needed; and * Number of occupants evacuated. The need to ensure fire drills were conducted according to the Oregon Fire Code, and all required information was documented, was discussed with Staff 1 (Administrator) and Staff 26 (Director of Facilities) on 11/08/22. They acknowledged the findings.

1) The fire drill form will be amended so that there is an area for the information to be filled in by Maintenance/Security staff. 2) The Maintenance/Security staff conducting the drill will write in which escape route was used, what time it occurred and how many residents were evacuated. The staff member will also comment on any issues that occurred during the drill, such as, any residetns who may have resisted or failed to participate in the drill. 3) This will be accomplished every other month. 4) Director of Facility Services and/or Maintenance Supervisor

Based on interview and record review, it was determined the facility failed to ensure residents were re-instructed on fire and life safety procedures at least annually. Findings include, but are not limited to: Fire and Life Safety records from 05/2022 through 11/2022 were reviewed on 11/08/22. There was no documented evidence of a written record, including content and residents attending, of annual instruction to residents on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building in the event of an actual fire. The need to ensure residents were provided instruction as required by the Oregon Fire Code was discussed with Staff 1 (Administrator) and Staff 26 (Director of Facilities) on 11/08/22. They acknowledged the findings.

1) Fire and Life Safety procedure written up for residents to sign at their annual service plan 2) At the top of our service plan, there is a check off box for annual service plans. This will trigger the Care Coordinators to train the residents and have them sign. 3) Audited Quarterly 4) Compliance Specialist

Based on observation and interview, it was determined the facility failed to ensure the doors that exited to the interior courtyards were equipped with an operational alarming device or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: The interior of the facility was toured on 11/07/22 and 11/08/22. There were three exit doors in the memory care unit through which residents could enter the secured MCC courtyard, and two exit doors in the residential care facility (RCF) through which residents could enter the RCF courtyard. When the surveyor exited through these doors, no audible alert was heard. Interviews on 11/08/22 with Staff 26 (Director of Facilities) and Staff 1 (Administrator) confirmed there was no system that alerted staff when a resident exited into the courtyards of the memory care unit and RCF. Staff 1 acknowledged the facility needed to install a system that alerted staff when a resident exited the building.

1) During survey, 5 motion sensors that will alert staff that someone is going into the courtyard were installed. The rest were ordered and have been installed on the rest of the courtyard doors. 2) Motion sensors have been installed on all needed courtyard doors. 3) Monthly inspection of alarms for placement and function. 4) Security

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Please refer to C 372, C 420, C 422, and C 555.

1) To ensure that the training records are in compliance, we have redone our entire onboarding process. This is to ensure that each new staff member has all the pre-service training, and within 30 days of hire training. 2) Policy and procedure written to ensure that new staff will not be allowed on the floor until they have had CM orientation, Manor Care orientation, Caregiver 101, Heartfelt Connections. Caregiver 101 and Heartfelt Connections have all the required pre-floor training and within 30 days of hire training as required by regulations. This program has been approved by Leading Age Oregon. We have also updated our caregiver check off list for when they are training on the floor. 3) Staffing Coordinator will audit entire hiring record to ensure record is complete and compliant. 4) Staffing Coordinator and Administrator or designee

Based on interview and record review, it was determined the facility failed to ensure 2 of 3 sampled newly-hired direct care staff (#s 20 and 24) completed all required pre-service orientation, pre-service dementia training and demonstrated competencies within required timelines. Findings include, but are not limited to: Training records were reviewed with Staff 28 (Staffing Development Coordinator) 11/07/22 through 11/09/22. The following deficiencies were identified: a. Staff 24 (CG) was hired 06/13/22. There was no documented evidence Staff 24 completed the required pre-service orientation in resident rights and values of CBC care prior to beginning job duties and completed the following required pre-service dementia care training topics prior to providing care and services independently: * Dementia disease process including progression of the disease, memory loss and psychiatric and behavioral symptoms; * Techniques for understanding, communicating and responding to distressful behavioral symptoms; * Strategies for addressing social needs and engaging persons with dementia in meaningful activities; * Specific aspects of dementia care and ensuring safety of residents with dementia including addressing pain, providing food/fluids, preventing wandering, use of person-centered approach; * Environmental factors that are important to a resident's well-being; * Family support and the role the family may have in the care of the resident; * How to recognize behaviors that indicate a change in the resident's condition and report behaviors that require on-going assessment; * How to provide personal care to a resident with dementia, including an orientation to the resident's service plan; and * Use of supportive devices with restraining qualities in MCCs prior to working independently. There was no documented evidence Staff 24 demonstrated competencies in the following required areas within 30 days of hire: * Role of the service plan in providing individualized care; * Providing assistance with ADL's; * Changes associated with normal aging; * Identification, documentation and reporting changes of condition; * Conditions that require assessment, treatment, observation and reporting; and * General food safety, serving and sanitation. b. Staff 20 (CG) was hired 05/18/22. There was no documented evidence Staff 20 demonstrated competencies in the following required areas within 30 days of hire: * Providing assistance with ADL's; and * Changes associated with normal aging.   The need to ensure newly-hired direct care staff completed all required pre-service orientation, pre-service dementia training and demonstrated competencies within required timelines was discussed with Staff 1 (Administrator), Staff 5 (Memory Care Coordinator) and Staff 28 on 11/09/22. They acknowledged the findings.

1) We have redone our entire onboarding process to include making sure that staff will have all preservice training and 30 days within hire training as needed for compliance. 2) Policy and procedure written to ensure that  newstaff will not be allowed on the floor until they have had CM orientation, Manor Care orientation, Caregiver 101 and Heartfelt Connections. Caregiver 101 and Heartfelt Connections have all the required prefloor, preservice, and within 30days of hire training. This program has been approved by Leading Age Oregon. We have also updated our caregiver check off list for when they are training on the floor. 3) Staffing Coordinator will audit entire hiring record to ensure record is complete and compliant 4) Staffing Coordinator and Administrator or designee

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Please refer to: C 160, C 252, C 260, C 262, C 270, C 280, C 302, and C 330.

1) We have redone our entire onboarding process to include making sure that staff will have all pre-service training, all within 30 days of hire training, and this includes changes associated with normal aging and abdominal thrust return demonstration. 2) Policy and Procedure written to ensure that new staff will not be allowed on the floor until they have had CM orientation, Manor Care orientation, Caregiver 101, and Heartfelt Connections. Caregiver 101 and Heartfelt Connections have all the required pre-floor, pre-service, and within 30 days of hire training. This program has been approved by Leading Age Oregon. We have also updated our caregiver check off list for when they are training on the floor. 3) Staffing Coordinator will audit entire hiring record to ensure record is complete and compliant. 4 Staffing Coordinator and Administrator or designee

Based on observation and interview, it was determined the facility failed to consistently ensure residents were not locked out of their rooms. Findings include, but are not limited to: During the survey, observations of the memory care unit showed all apartment doors had an electronic locking system in place. The doors remained locked at all times when closed and required a key fob for every entry into the room.  Any individual who wanted or needed to enter an apartment with a closed door had to utilize a key fob to do so. Caregiving staff each carried a key fob which could open residents' rooms. Six residents were observed with key fobs on their person or attached to walkers. The residents were unable to state what the key was for or what it did. An additional eleven residents were observed with no key fob. Four residents were observed attempting to open their apartment doors, the doors were locked and residents were unable to enter. A non-sampled resident stated it made him/her "so angry," as s/he repeatedly pulled on the door knob. Observations of Resident 2 and 4 and additional non-sampled residents, who required staff assistance to get out of bed and leave the apartment, showed visitors were unable to access the residents without staff intervention. The surveyor knocked on Resident 2 and 4's doors on 11/07/22. The residents yelled out "come in" repeatedly but the surveyor was unable to open the doors as they were locked. Once a staff was located they were able to temporarily unlock the residents' doors to allow the surveyor access. Additional observations of Resident 4 on 11/07/22 showed the resident yelling out for help, moaning and groaning. The resident responded to the surveyor's knock and questions through the door. The resident said come in and replied s/he needed help. The surveyor told the resident help was on the way and to stay seated. A staff member was located and the resident's door was opened. The resident was seated in his/her recliner and told staff s/he needed help. During interviews with multiple memory care staff between 11/07/22 and 11/08/22, the staff stated the doors would open with a key fob but were not unlocked. Staff stated some of the residents in the unit did have key fobs for their apartments but only a few of the residents understood how to use them. The staff further indicated a resident or a visitor just needed to locate a staff member to let them into apartments. The need to ensure residents were not locked out of their apartments and that those visiting the resident could access the resident when the resident requested they enter was discussed with Staff 1 (Administrator), Staff 2 (Director of Nursing Services), Staff 3 (Compliance Specialist) and Staff 5 (Memory Care Coordinator) on 11/09/22. The staff acknowledged the findings.

1) An evaluation of each resident will be done. 2) Staff will ask each resident if they: * Have a fob * If they know how to use it * Ask them to demonstrate * Staff will make sure  that the resident has a fob if they want it and can use it * Staff will ask if they want their door unlocked all the time If the resident is unable to answer due to their advanced dementia, we will call the family and ask  them what they think the resident would want. All information will be added to the service plan 3) Quarterly with service plan review 4) Resident Care Coordinators

The findings of the re-licensure survey, conducted 11/07/22 through 11/09/22, 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 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004. Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC: Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the re-visit to the re-licensure survey of 11/09/22, conducted 03/21/23 through 03/22/23, are documented in this report. It was determined the facility was in compliance with OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.