Avamere at Seaside Residential Care Facility

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:? Observations of the facility kitchen, food storage, and dining room areas on 12/06/24 between 11:00 am and 12:23 pm noted the following in need of cleaning or repair:? a. Main Kitchen Area * Doors and door jambs throughout the kitchen had black and brown scuff marks or gouges on the wood and were observed to have chipped paint; * The back screen door was observed to have dust on the screen and black matter on the lower section of the door; * Cutting boards, including the one attached to the Sandwich Cooler Station, were observed to have score marks and gouges deeming them to be uncleanable; * Black and brown matter was observed throughout the baseboards of the kitchen as well as where the door jambs connected with the floor; * Areas under the large appliances had a thick build-up of black and brown matter; * There was a build-up of drips and splatters on the legs of the steam table; * The hood of the stove was in need of deep cleaning; * A section above the hood of the stove was missing and bare wood was exposed; * Vents located throughout the kitchen ceiling had dust accumulation observed on them and the ceiling around the vents; * The stand-up mixer had dried food debris present; * The industrial can opener had built up food matter on the blade; and * The outside of the dried storage bins had brown debris observed; and *Three garbage cans, observed in food prep areas, did not have lids. b. Dry Food Storage Area * Flooring throughout the area, including the threshold, had black and brown matter observed and was sticky to step on; * There was a crack in a linoleum tile within approximately a foot from the entry point; * Walls throughout the area had gouges and scuff marks observed; and * The door frame was observed to have gouges in the wood and chipped paint. c. Warewashing Area * Flooring underneath the warewashing machine and all of the sinks along the shared wall had black and brown debris present; * There was black matter observed on the wall behind the sink; and * There was debris build-up observed on the garbage disposal switch located to the right, under the sink. e. Memory Community Dining Room * Exit and entrance doors had black and brown scuff marks and/or were observed to have gouges and chipped paint; * The door leading into the kitchenette were observed to have black and brown scuff marks, gouges in the door frame, and chipped paint; and * The middle cupboard, under the dining room beverage station, had chipped laminate observed on the left upper corner. The areas in need of cleaning and repair were reviewed with Staff 1 (Dietary Manager) on 12/06/24. She acknowledged the findings.?

1. All areas of note in both kitchens have been deep cleaned. All doors in both kitchens have been cleaned. Baseboards and floors have been scrub mopped, walls and vents wiped down, legs of appliances cleaned, hood vents cleaned, stand-up mixer deep cleaned. Done by 12/13/24. Section above hood with exposed wood was fixed 12/15/24. Cutting boards replaed 1/2/25. Gouges and chipped paint, crack in linoleum near entry, middle cupboard with chipped laminate have been discussed with Maintenance Director and submitted to TELS (Completion date Week of Jan 20-24). 2. Weekly checks by the Dietary Manager and cleaning schedules for both kitchens will be signed by staff and turned in to DM for review and any follow up if needed. Hood cleaning with be completed by Oregon Hood Cleaning every 6 months and staff will clean hoods 3 months after each cleaning and will be tracked by DM. Vents will be checked and tracked by DM every 3 months. In-service instructions were given to employees regarding lids for trash cans and DM will check weekly. 3. System will be evaluated and tracked monthly as a part of the CQI process to include a review of the monthly kitchen sanitation audits. 4. The Arbor Administrator, Executive Director and RCC will be responsible for maintaining / and audit this system.

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

Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:? Observations of the facility kitchen, food storage, and dining room areas on 03/18/25 between 11:15 am and 12:30 pm noted the following in need of cleaning or repair:? a. Main Kitchen Area * Doors and door jambs throughout the kitchen had black and brown scuff marks or gouges on the wood and were observed to have chipped paint; and * Areas under the large appliances had a thick build-up of black or brown matter. b. Dry Food Storage Area * The door frame was observed to have gouges in the wood and chipped paint. c. Warewashing Area * Flooring underneath the warewashing machine and all of the sinks along the shared wall had black and brown debris present; d. Memory Community Dining Room * The doors leading into the kitchenette were observed to have gouges in the door frame. The areas in need of cleaning and repair were reviewed with Staff 1 (Dietary Manager) and Staff 3 (ED) on 03/18/25. They acknowledged the findings.?

1. Gouges in wood doors in both kitchens are being filled in by Maintenance Director to be completed by 4/7/25. Door frame to dry storage area is cleaned and painted as of 3/31/25. Flooring underneath warewashing machine has been deep cleaned as of 3/25/25. Deep cleaning of black matter completed 3/27/25. Scrub mopping of baseboards and floor in main kitchen completed 3/27/25. 2. Weekly checks by the Dietary Manager and cleaning schedules will be signed by staff and turned in to DM for review and any follow up if needed. 3. System will be evaluated and tracked monthly as a part of the CQI process to include a review of the monthly kitchen sanitation audits. 4. The Executive Director, Arbor Administrator, and RCC will be responsible for maintaining and audit this system.

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

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

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

Refer to 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.

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

see C 240

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 observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to: Refer to C240 and Z142.

see 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.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight to ensure quality of care and services rendered in the facility. Findings include, but are not limited to: During the relicensure survey, conducted 06/27/22 through 06/30/22, administrative oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the scope and number of citations. Refer to deficiencies in report.

See POC for all individual tags.  Administrator will be doing additional training at another facility.  Administrator is also taking Leading Age Role of the Nurse in the Community August 23-25 and has completed the self-study RN delegation course.

Based on observation and interview, it was determined the facility failed to ensure residents could exercise individual rights that do not infringe upon the rights or safety of others and to associate and communicate privately with any person of choice. Findings include, but are not limited to: 1. Observations of sampled and non-sampled residents and interviews with family and staff conducted during the survey revealed the following: a) During an interview on 06/29/22 at 9:20 am, Resident 3's family member stated the family had not been able to visit Resident 3 in his/her room for a while because s/he had a roommate and the facility was requesting the family visit Resident 3 in a separate room. b) During an interview with Staff 1 (Administrator) on 06/28/22, the facility visitor policy was discussed. Staff 1 stated the facility policy included restrictions on visitors that included limiting where people could visit and not allowing visitors during a COVID outbreak.   c) During observations on 06/28/22 at approximately 1:30 pm, a visitor on the memory care unit was escorted out of the unit by a staff member and told s/he was not able to visit the facility at this time due to a COVID outbreak in the facility. On 06/28/22, Staff 1 was provided a copy of the provider alert, dated March 31, 2022, that included instructions on post public emergency guidance for facilities related to visitation. The document was reviewed with Staff 1, who acknowledged the facility was misinformed and would contact families to let them know visits would be allowed, and PPE would be provided for in-room visits if this was the resident's need or preference. The need to ensure resident's rights to receive visitors was not infringed upon was discussed with Staff 1 and Staff 2 (RN) on 06/30/22. They acknowledged the findings.

1. All families were contacted and updated on the current regulatory guidelines for visitation during an outbreak.   2. Any updated regulatory changes to visitation or other protocol that may affect resident rights will be reviewed by the Arbor Administrator and ED. 3. As changes in regulation occur, Arbor Administrator and Executive Director will review and update all staff, residents and families as indicated.   4.  The Arbor Administrator and Executive Director will be responsible for monitoring for compliance.

Based on interview and record review, it was determined the facility failed to conduct an investigation of unwitnessed falls that ruled out abuse or neglect for 1 of 3 sampled residents (#1) who experienced falls. Findings include, but are not limited to: Resident 1 was admitted to the facility in 09/2020 with diagnoses including dementia and Parkinson's disease. The clinical record revealed: Between 04/14/22 and 05/03/22, the resident experienced four falls. Incident reports from 04/15/22 through 05/15/22 were reviewed. The facility was unable to provide documented evidence the facility immediately investigated the unwitnessed falls to rule out abuse or neglect or reviewed the service plan to see if it was being followed. The need to ensure a timely and thorough investigation of falls and injuries was completed and that service plans were being followed to prevent further falls was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/30/22. They acknowledged the findings.

1. A thorough root cause analysis has been completed for resident #1, including a review of falls in the past quarter. Service plan has been updated with current interventions and reviewed by all direct care staff. 2. Arbor Administrator, RN and Executive Director reviewed the abuse and neglect reporting guidelines and the need for thorough and timely investigations, including a review of the service plan and investigation as to whether previous interventions are being followed and proper documentation of such investigations is completed. Staff have been inserviced on the IR and reporting and investigation process. 3. Incidents reports will be reviewed to ensure proper response and investigation as a part of daily standup meeting. As part of the monthly CQI process, residents with frequent falls will be reviewed to ensure interventions are on the service plan and being followed. Incident report review will include a thorough investigation, including a review of the service plan and any previous interventions. If unable to rule out abuse and neglect, incidents will be reported to APS.   4. The Arbor Administrator, Executive Director and RN  will be responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was kept clean and in good repair, in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to: A. On 06/27/22 at 10:50 am, the facility main kitchen was observed. The following areas were in need of cleaning: Black matter, debris, grease, food matter and dirt buildup were observed on or underneath the following: * Floor and drain underneath the ice machine; * Exterior and interior of ovens and fryer; * Steam chef next to ovens; and * Floor underneath dish machine. The following area needed repair: * A kitchen door leading outside was open. A screen on the door was not attached, leaving an open gap, which allowed insects into the kitchen. The areas that required cleaning and repair were observed and discussed with Staff 3 (Dietary Manager) at 11:20 am the same day. The findings were acknowledged. B. Observation of the MCC kitchenette on 06/27/22 at 12:05 pm revealed the following areas were in need of cleaning: Black matter, debris, grease, food matter and dirt buildup were observed on or underneath the following: * Interior of refrigerator and freezer; * Shelving underneath the steam table; * Wall behind the hand wash sink; * Floor perimeter and in grout lines between tiles; and * Interior and exterior of microwave. Additionally, the trash can in the kitchenette did not have a lid. The areas that required cleaning were observed and discussed with Staff 1 (Administrator) on 06/28/22 at 9:30 am. The findings were acknowledged.

1. All identified areas in the main and Arbor kitchen have been deep cleaned.  Door to the kitchen has been repaired.  Garbage can with lid has been ordered and will arrive on 7/26/2022. 2. Daily checks by the Dietary Manager and cleaning schedules for both kitchens will be signed by staff and turned in to the Dietary Manager for review and any follow up needed. DM will complete a monthly kitchen sanitation audit and ensure any deficencies will be corrected timely. 3. System will be evaluated monthly as part of the CQI process to include a review of the monthly kitchen sanitation audits. 4. The Arbor Administrator, Executive Director and RN  will be responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental and psychosocial needs. Findings include, but are not limited to: Observations made on the memory care unit between 06/27/22 and 06/30/22 revealed there were no group activities occurring on a consistent basis. Multiple residents who were in the common areas, throughout the survey, were not provided any individual or group activities. Residents were observed sitting in common areas for long periods of time watching television, people-watching or remained in their rooms. Multiple residents were observed pacing the halls frequently without being engaged in any individual or group activities. The activity calendar was posted on the unit and observations included the following: * On 06/27/22, chair exercises, brain boosters, bird watching, bingo and "name it game" were scheduled on the unit but not offered; * On 06/28/22, "video connections", chair volleyball and "Rem Arc" were scheduled on the unit but not offered; and * On 06/29/22, music and movement, gardening club, roll dice and coloring craft were scheduled on the unit but not offered. During an interview on 06/29/22, Staff 1 (Administrator) stated the facility had a life enrichment director and activity aide, however, both were currently on vacation. Staff 1 acknowledged there was no plan in place for providing activities in the absence of the life enrichment staff. Interviews on 06/27/22 and 06/28/22 with multiple facility staff revealed there had been extended periods of time without life enrichment staff due to "staff turnover" in the past several months. During observations on the unit on 06/28/22 and 06/29/22, Residents 5 and 6 were observed pacing the halls and made comments including "there's nothing to do", "I don't know what we can be doing now" and "I'd like to go out of here to do things." Direct care staff acknowledged there was no activity occurring to direct residents to participate in when they appeared to be bored or in search of something to do. The need to provide a daily program of social and recreational activities that were based upon individual and group interests, physical, mental and psychosocial needs was discussed with Staff 1 on 06/29/22. She acknowledged the findings.

1. In the event the LED (Life Enrichment Director) is not available to guide activities, the Arbor Administrator will review calendar and ensure that activities are being performed as scheduled or an alternative event is created. 2. Activity calendar will be reviewed during daily stand up meeting, 5 days a week.  If the LED is unavailable, the Arbor Administrator will designate another staff member to administer the activities.  Staff will be trained on 1:1 activities and they will be scheduled for times when there is no activity staff in the building. 3. The Activity calendar will be reviewed stand up meeting weekly and monthly at CQI.  Life Loop technology will be used to document attendance. 4. The Executive Director and Arbor Administrator are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required components for 1 of 1 sampled resident (#6) whose new move-in evaluation was reviewed. Findings include, but are not limited to: Resident 6 moved into the MCC on 06/16/22. The new move-in evaluation failed to address the following elements: * Customary routines; * Interests, hobbies and social and leisure activities; * Spiritual and cultural preferences and traditions; * List of medications and PRN use; * Visits to health practitioners, emergency room, hospital or nursing facility in the past year; * History of treatment of mental health issues; * Personality, including how the person copes with change or challenging situations; * Nutrition habits, fluid preferences and weight if indicated; * List of treatments: type, frequency and level of assistance needed; * Recent losses; * Unsuccessful prior placements; and * Environmental factors that impact the resident's behavior including noise, lighting and room temperature. The need to ensure move-in evaluations included all required elements was discussed with Staff 1 (Administrator) on 06/29/22 at 2:09 pm. She acknowledged the findings.

1. Evaluation and service plan for resident #6 has been updated to include all required components. 2. To prevent reccurence, facility will complete preadmission and admission evaluations per regualtion and company policy on all new residents. Facility to utilize admisision checklist to ensure preadmission and admission evaluations are completed. Evaluations will then be completed within 30 days, quarterly and with significant change of condition. 3. This system to be audited utilizing the clinical admission checklist which includes components to be audited prior to admission, upon admission, 72 hours from admission and at 30 days. This system will be evaluated monthly as part of our CQI program. 4. The Arbor Administrator and Executive Director are responsible for maintaining this system.

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, and/or were followed for 2 of 5 sampled residents (#s 2 and 6) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in 04/2021 with diagnoses including Alzheimer's dementia, hypertension and risk of falls. Observations and interviews with direct care staff during the survey revealed Resident 2 had not been out of bed for "about" two months, was non-weight bearing  and all care was provided in bed. Resident 2's service plan dated 06/07/22 was not reflective of the resident's current needs, and did not provide clear direction to staff in the following areas: * Involvement in activities; * Bed bound status; * Mobility and transferring, including use of devices; * Bathing and toileting; * Falls; * Dining routine; and * Weight monitoring. The need to ensure service plans were reflective of the resident's needs and included clear direction to staff was discussed with Staff 1 (Administrator) on 06/29/22 at 3:30 pm. She acknowledged the findings. 2. Resident 6 was admitted to the facility in 06/2022 with diagnoses including dementia and visual and auditory hallucinations. Review of the most current service plan dated 06/16/22 and observations and interviews conducted between 06/27/22 and 06/29/22, revealed Resident 6's service plan was not reflective, did not provide clear instruction to staff and/or was not followed in the following areas: * Housekeeping; * Bathing; * Wandering; * Toileting; * Interventions for anxiety; * Foot care needs; * Fingernail care; * My Story; * Dietary preferences; and * Dining assistance. The need to ensure service plans were reflective of the identified needs and preferences of the resident, provided clear direction to staff and were followed by staff was discussed with Staff 1 (Administrator) on 06/29/22 at 2:09 pm. She acknowledged the findings.

1. Service plans for resident #2 and resident #6 have been updated to be reflective of current needs and interventions, including clear instructions to staff and have been printed for staff to review. 2. To prevent recurrance, all current resident service plans will be audited for accuracy. Direct care staff will be reeducated regarding the importance of reporting any questions or concerns related to resident service plans as well as reviewing all ISPs as part of shift change. A form was implemented for care staff to document any discrepancies between resident service plans and actual care needs. Form is to be turned into Arbor Administrator so that service plans can be updated and reflective. 3. Interim Service Plans (ISPs) will be  reviewed at standup as part of the 24hr/72hr summary review (includes all progress notes written in past 24/72 hours), and service plans will be updated as needed. Service plans will be evaluated and reviewed by all departments upon admission, at 30 days, quarterly and with significant change of condition. 4. The Arbor Administrator and Executive Director will be responsible for maintaining this system.

3. Resident 2 moved into the facility in 04/2021 with diagnoses including Alzheimer's dementia, chronic kidney disease and hypertension. Observations during the survey, review of Resident 2's progress notes from 03/28/22 through 06/25/22, Staff 2 (RN) interview on 06/29/22 and direct care staff interviews during the survey revealed the following: a. A progress note dated 04/04/22 stated Resident 2 was not drinking much and had no urination. On 04/04/22, an outside provider visit note recommended to push fluids and for the facility to notify the outside agency if no urine output continued. The short term change in condition lacked documented evidence of monitoring through resolution. b. Resident 2 was observed in bed and received all care in bed during the survey. Direct care staff reported that Resident 2 had declined, had not been out of bed for two months, and was now non-weight bearing. There was no documented evidence Resident 2's changes in condition had been evaluated, referred to the facility RN, service plan updated, and interventions communicated to direct care staff. The need to evaluate changes of condition, refer significant changes to the RN, identify and communicate interventions, update the service plan, and monitor the interventions for effectiveness until resolved was discussed with Staff 1 (Administrator) on 06/29/22 at 3:30 pm. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure interventions were developed, communicated to staff and monitored for effectiveness following changes of condition and, at least weekly, document progress of short-term changes of condition to resolution for 3 of 3 sampled residents (#s 1, 2 and 5) who experienced changes of condition, including weight loss, skin wounds, falls and dehydration. Resident 5 experienced continued, severe weight loss. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. A review of the resident's service plan, signed by Staff 1 (Administrator) on 05/24/22, progress notes and facility incident reports dated between 04/07/22 and 06/27/22 revealed the following: a. The service plan identified the resident as having "decreasing weight", last revised on 05/17/22. Interventions and instruction to staff included "weigh monthly", "keep family and PCP informed of weight loss", and "give finger foods if will not sit down for dinner". The service plan also instructed staff to "provide cueing/prompting during meals" and to "remind the resident of meal times". b. Observations of the resident from 06/27/22 through 06/29/22 showed the resident spent long hours pacing the hallways of the unit. Staff provided cuing to the resident when meals were served on the unit and provided reminders to the resident to sit and eat meals when they were on the table. On 06/29/22, a cart of snacks was delivered to the unit at 10:00 am and snacks were placed in the refrigerator of the kitchenette near the dining room. Resident 5 was not offered a snack. The resident was provided a Philly cheese steak sandwich and four pickled beets at the lunch meal. The resident ate 100% of the meal, then stood to leave the table. Care staff in the dining area provided multiple cues for the resident to sit and wait for "some pie". The resident intermittently stood and sat for ten minutes following completing the meal then resumed walking and pacing the unit. c. On 06/28/22, weight records were requested and the following weight information was provided: * 04/07/22: 152.6 pounds (admission weight); * 05/09/22: 138.0 pounds; * 06/01/22: 135.8 pounds; and * 06/29/22: 131.8 pounds (weight taken per surveyor request). d. The facility was unable to provide documentation that the ongoing weight loss was evaluated, reported to the physician or that additional interventions had been identified and communicated to staff, and monitored at least weekly. The facility's failure to evaluate the resident's weight loss, determine and document actions or interventions to prevent further weight loss or to monitor interventions for effectiveness put the resident at risk for continued weight loss. e. Resident 5's clinical record documented s/he experienced urinary tract infections (UTIs) on 05/24/22 and 06/18/22 and was provided with a heart monitor on 04/27/22. The facility was unable to provide documented evidence that care staff was provided instructions, interventions or monitoring of these changes of condition and service plan changes. The need to ensure residents who experienced a change of condition were evaluated, resident specific actions or interventions were developed, communicated to staff and monitored was discussed with Staff 1 and Staff 2 (RN) on 06/29/22. They acknowledged the findings. 2. Resident 1 was admitted to the facility 09/2020 with diagnoses including dementia and Parkinson's disease. The resident was dependent on staff for transfers and most ADL care. A review of the resident's clinical record and documentation between 03/30/22 and 06/27/22 indicated the resident had experienced the following change of condition: a. On 04/21/22, care staff documented an open wound on the resident's buttock area and instructed staff to "start wound care". Staff 11 (MT) documented the wound size and to "follow physician treatment orders and instructions by the facility RN". b. On 05/24/22, progress notes contained documentation of treatment orders for "duoderm dressings for pressure sore". The record lacked documentation that the wounds were monitored, at least weekly, to determine effectiveness of interventions. c. Resident 1 experienced four falls between 04/14/22 and 05/03/22. The record lacked documented evidence that interventions identified in the fall investigations were communicated to staff, followed or monitored for effectiveness.   The need to ensure each resident was monitored for changes of condition and documentation of the changes and interventions was completed, at least weekly, until resolution was discussed with Staff 1 and Staff 2 on 06/30/22. They acknowledged the findings.

1. Residents #1, #2 and #5 have been assessed by RN and service plans have been updated to include all necessary interventions have been added which include clear direction to direct care staff.  Weights and diet orders have been reviewed for all residents. Assessments are being completed based on weight results. 2. To prevent recurrence, staff will be reeducated on our alert charting guidelines and when to notify the RN. 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72-hour summary will be reviewed to include review of all documentation from the weekend. When a change of condition is identified, the resident will be placed on alert charting which will include a RN assessement, which will include any changes to the plan of care. When a change of condition is determined to be a significant change, a comprehensive nursing assessment will be triggered for the RN to complete and the condition will be monitored until resident is stable. The RN is scheduled to take the Leading Age Role of the Nurse in the Community, August 23-25. 3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring. 4. The Arbor Administrator, Executive Director and RN are responsible for maintaining this system.

3 . Resident 2 was admitted into the facility in 04/2021 with diagnoses including Alzheimer's dementia, hypertension and risk of falls. During the survey entrance acuity interview on 06/27/22 with Staff 1 (Administrator), Resident 2 was identified as having a significant decline and had been placed on palliative care services. Observations during the survey, review of Resident 2's progress notes and service plan, and interviews with direct care staff revealed the following: Resident 2 remained in bed during the survey and all care was provided to the resident while in bed . Direct staff stated Resident 2 had not been out of bed in two months, was no longer weight bearing and no longer able to use assistive mobility devices that were in the room and by the bed. There was no documented evidence the facility RN completed an assessment of Resident 2's significant change of condition which included findings, resident status and interventions made as a result of the assessment. In an interview on 06/29/22 at 2:45 pm, Staff 2 (RN) verified that an assessment of the resident's changes of condition had not been completed. The need to ensure residents who experienced significant changes of condition were assessed by the RN and included findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 on 06/29/22 at 3:30 pm. She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, which included findings, resident status and interventions, for 3 of 3 sampled residents (#s 1, 2 and 5) who experienced significant changes. Resident 5 experienced continued, severe weight loss. Findings include, but are not limited to: 1. Resident 5 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Resident 5's clinical record, including, but not limited to, the current service plan, revised on 05/17/22, progress notes dated 04/07/22 through 06/27/22 and weight records from 04/07/22 through 06/29/22 were reviewed and revealed the following; a . On 06/28/22, weight records were requested and the following weight information was provided: * 04/07/22: 152.6 pounds (admission weight); * 05/09/22: 138.0 pounds; * 06/01/22: 135.8 pounds; and * 06/29/22: 131.8 pounds (weight taken per surveyor request). Between 04/07/22 and 05/09/22, Resident 5 lost 14.6 pounds, or 9.56% of his/her total body weight in one month, which is considered severe. Between 04/07/22 and 06/29/22 the resident lost a total of 20.8 pounds, or 13.63% of his/her total body weight in three months, which is considered severe. These represented significant changes of condition for which an RN assessment was required. There was no documented evidence an RN completed an assessment of the weight loss. The severe, continued weight loss represented a serious risk to the health, safety and welfare of the resident. Refer to C 270, example 1a. through 1d. In an interview on 06/28/22, Staff 2 (RN) stated she was aware the resident had been losing weight and confirmed an assessment had not been completed. While the facility had been discussing possible interventions, such as a nutritional supplement, none had been implemented. 2. Resident 1 was admitted to the facility in 09/2020 with diagnoses including dementia and Parkinson's disease. Resident 1 had an open pressure area identified in the progress notes on 04/21/22 and on 05/24/22. The open pressure wounds represented a significant change of condition, requiring an RN assessment. The facility was unable to provide documentation that an assessment was completed, that interventions had been identified and the condition was monitored, at least weekly, through resolution. In an interview on 06/29/22, Staff 2 stated she was aware the resident had a chronic wound that would re-open from time to time, but was not aware the resident currently had an open pressure area and confirmed an assessment had not been completed on either occasion. Refer to C270, example 2a. The need to ensure all significant changes of condition were assessed by an RN, with documented findings, resident status, and interventions made as a result of the assessment, was discussed with Staff 1 (Administrator) and Staff 2 on 06/29/22. They acknowledged the findings.

1. Residents #1, #2 and #5 have been assessed by RN and service plans have been updated to include all necessary interventions have been added which include clear direction to direct care staff. 2. To prevent recurrence, change of condition policy and procedure has been reviewed with RN and RN will be attending 'The role of the RN in community based care' training. To further prevent recurrance, 24 hour summary will be reviewed five days a week as part of daily standup meeting. On Mondays, the 72 hour summary will be reviewed to include review of all documentation from the weekend. When a significant change of condition is identified, a comprehensive nursing assessment will be triggered for the RN to complete and the condition will be monitored with weekly updates until resident is stable.  The RN is scheduled to take the Leading Age Role of the Nurse in the Community, August 23-25. 3. This system will be evaluated five days a week as part of daily stand up meeting. This system will further be evaluated monthly as part of the facility CQI process which includes a review of all residents who require significant change of condition monitoring as well as other audits to identify any changes that may have been missed by other systems. 4. The Arbor Administrator, Executive Director and RN are responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#4) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to: During the acuity interview on 06/27/22, Resident 4 was identified to be administered insulin injections by non-licensed staff. Resident 4's MARs, reviewed from 06/01/22 through 06/27/22, revealed insulin had been given by Staff 8, 11 and 12 (MTs) on multiple occasions. Review of delegation documentation revealed the following: a. Initial delegations for Staff 8 completed 03/01/22, and Staff 11 completed 03/01/22, lacked documentation in the following areas: * The skills and ability of the unlicensed person; * How frequently the resident should be reassessed by the RN, including rationale for the frequency based on the client's needs; * How frequently the unlicensed person should be supervised and re-evaluated, including rationale for the frequency based on the competency of the caregiver; and * That the RN took responsibility for delegating the task to the unlicensed person, and ensured that supervision would occur for as long as the RN was supervising the performance of the delegated task. Additionally, there was no documentation that Staff 2 (RN) re-evaluated Staff 8 and 11 within 60 days of the initial delegation. b. No delegation had been completed for Staff 12. The need to ensure staff who administered insulin injections was delegated in accordance with OSBN Division 47 Rules was discussed with Staff 2 (RN) on 06/28/22 at 3:00 pm. The RN Surveyor informed Staff 2 that unlicensed staff could not give insulin to Resident 4 without current delegation. Staff 2 acknowledged the findings.

1. All staff responsible for administration of insulin to resident #4 have the appropriate delegations in place per Division 45 and Division 47. This includes; the frequency for reassessment, documentation of observation of task, frequency of supervision and reevaluation, and resident assessment.  Written instructions for unlicensed staff, including parameters for notification to RN and providers, information for staff related to signs and symptoms to monitor for and who to notify are accessible and located in the facility 24-hour binder as well as the delegation binder.  Arbor administrator completed a comprehensive audit of all residents receiving delegated services for compliance with all required components. 2. To prevent recurrence the facility RN will review Division 47 and Division 45 and complete OSBN online self- study module by 8/14/22. RN will utilize a CBC RN delegation progress note to reassess residents with each new delegation, each re delegation and as needed for change of condition.  The RN will use facility CBC RN delegation form to document staff observation and competency, including current and next reassessment date for each staff member preforming the delegated task and each res receiving delegated services. Education material regarding signs and symptoms to observe and who to report negative symptoms to, will be maintained in the facility 24 -hour binder and accessible at all times to staff performing delegated tasks.   3. This system will be reviewed every other month as part of the facility CQI program and will include an audit of all delegated services for continued compliance with Division 45 and Division 47. 4. The RN, Arbor Administrator and Executive Director will be responsible for maintaining this system

Based on interview and record review, it was determined the facility failed to coordinate care with outside providers, ensure clinical information was reviewed by the facility nurse, staff were informed of new interventions and the service plan adjusted as necessary for 1 of 1 sampled resident (#2) who received outside health services. Findings include, but are not limited to: Resident 2 moved into the facility in 04/2021 with diagnoses including Alzheimer's dementia, hypertension, chronic kidney failure and risk of falls. Staff 2 (RN) interview on 06/29/2022 and review of clinical records including the service plan, outside provider visit notes and facility progress notes revealed the following: a. During an outside provider visit on 04/29/2021, three direct care staff received bed mobility and transfer training for Resident 2, including using a transfer board. Recommendations were noted in the outside provider visit summary and in the facility progress notes on 04/29/2022. There was no documented evidence the facility updated the resident's service plan with these instructions or communicated the bed mobility and transfer instructions to all direct care staff. b. On 06/29/22 at 2:45 pm, Staff 2 (RN) confirmed that the outside provider had placed Resident 2 on palliative care services on 04/28/2022. There was no documentation of the outside provider visits and recommendations with care instructions for staff for palliative care. There was no documented evidence the information regarding palliative care services provided by the outside agency was reviewed by the RN and the service plan was updated with instructions or communicated instructions to staff. The need to ensure coordination between the facility and outside service providers was reviewed with Staff 1 (Administrator) on 06/29/22 at 3:30 pm. She acknowledged the findings.

1. All outside provider summary notes for the past 90 days have been reviewed for resident #2 and service plan has been updated with all recommendations and appropriate interventions. Service plan has been printed for all direct care staff to review. 2. To prevent recurrance all outside provider notes to be reviewed through facility triple check process, which includes review by RN. All information provided by outside providers will be followed up on by RN and steps will be taken as needed to update service plans and treatment plans accordingly.  Coordination of care will be performed by RN with all outside health services to ensure appropriate care and services are provided within the scope of the regulation and practice.    3. This system will be evaluated semi-annually as part of the facility's CQI program. 4. The Arbor Administrator, Executive Director and RN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to have signed orders for all medications and failed to ensure orders were carried out as prescribed for all medications administered by the facility for 2 of 2 sampled residents (#s 2 and 5) whose orders were reviewed. Findings include, but are not limited to: 1. Resident 2 moved into the facility in 04/2021 with diagnoses including Alzheimer's dementia, risk of falls and hypertension. Resident 2's 06/01/22 through 06/26/22 MARs and physician's orders dated 03/08/22 were reviewed and revealed the following: a. There was no documented evidence the facility had signed physician orders for the following medications: * Sertraline (for major depressive disorder); * Atrophine Sulfate (for excessive secretion); * Haloperidol Lactate Concentrate (for agitation hallucination); * Lorazepam Intesol Concentrate (for anxiety); and * Morphine Sulfate Solution (for pain and shortness of breath).   The need to ensure signed physician's orders were complete and in place for all medications administered by the facility was discussed with Staff 1 (Administrator) on 06/29/22 at 3:30 pm. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2022 with diagnoses including Alzheimer's disease. Resident 5's 06/01/22 through 06/28/22 MARs and current medication orders were reviewed and included the following: a. On 05/20/22, the physician ordered: * Trazodone, 50 mg. Give 1 tablet by mouth as needed for insomnia. The order on the MAR showed: * Trazodone, 100 mg. Give 1 tablet by mouth as needed for insomnia. Give 1 tablet by mouth nightly." The facility was not able to provide a physician's order for the 100 mg dose of Trazodone; b. On 05/11/22, the physician ordered Sertraline, 100 mg daily. The order was not included on the resident's MAR and the facility was not able to provide documentation of a physician's order to discontinue the Sertraline; and c. On 06/29/22, direct care staff reported Resident 5 had been "up all night" on 06/28/22, walking and pacing on the unit. Staff 8 (MT) was interviewed to determine whether the PRN medication for insomnia had been administered. Staff 8 verified the resident did not receive Trazodone PRN or Melatonin PRN for insomnia on the night of 06/28/22. The need to ensure signed physician's orders were documented in the facility record and medications were administered as ordered was reviewed with Staff 1 (Administrator) and Staff 2 (RN) on 06/30/22. They acknowledged the findings.

1. Physician orders for residents #2 and #5 have been reconciled to original orders to ensure accuracy and have been sent to provider for review and signature. Orders will be updated to clearly reflect reason for use. Medication aides will be re-educated on proper PRN usage and documentation. 2. To prevent recurrance, all new orders will go through a triple check process, which includes RN review for accuracy of order transcription as well as RN review for clear instructions for use. EMAR administration progress notes will be reviewed as part of the 24 hour daily audit (72 hour audit on Mondays) to ensure appropriate documentation. Ongoing education will be provided to medication aides as needed based on findings of audits. 3. Clear instructions for PRN use will be evaluate monthly as part of our CQI audits. All medication and treatment orders will be reconciled quarterly and sent to provider for review and signature. 4. Arbor Administrator, Executive Director and RN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included specific instructions for PRN medications for 2 of 3 sampled residents (#s 2 and 5) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2 admitted to the facility in 04/2021 with diagnoses including Alzheimer's dementia, hypertension and depressive disorder. Resident 2's MARs for 06/01/22 through 06/26/22 and physician orders dated 03/08/22 were reviewed and revealed the following: a. The orders for Sertraline (for depressive disorder) on the physician's orders and the MARs did not match. b. The following PRN medications lacked parameters for administration: * Acetaminophen suppository 650 mg, Acetaminophen tablet 325 mg and Hydrocodone-Acetaminophen tablet 325 mg (for pain) lacked clear parameters on when to administer one versus the other and in what order; and * Ondansetron HCI tablet 4mg and Ondansetron HCI 8 mg  (for nausea) lacked clear parameters on when to administer one versus the other.   The need to ensure MARs were accurate and included clear parameters for PRN medication was discussed with Staff 1 (Administrator) on 6/29/22. She acknowledged the findings. 2. Resident 5 was admitted to the facility in 04/2022 with a diagnoses including Alzheimer's disease. Resident 5's 06/01/22 through 06/27/22 MARs were reviewed. The following PRN medications lacked clear parameters for administration: * PRN Melatonin, 10 mg and PRN Trazodone, 50 mg were both prescribed to be given for insomnia. The physician's order for Melatonin included a parameter to "give as needed if Trazodone ineffective". The parameter had not been transcribed to the MAR, therefore, MTs did not have direction as to which medication to administer first. The need to ensure MARs included clear parameters for multiple PRN medications that were prescribed to treat the same condition was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/30/22. They acknowledged the findings.

1. A complete MAR audit for all residents was done by Regional Nurse Consultant along with DHS and Arbor Administrator to provide training and ensure all PRN orders have specific instructions for staff. If there is more than one medication ordered for the same purpose, instructions include the order in which medications should be administered. Most PRN parameters have been updated. 2. To prevent recurrence, audits will be completed monthly to ensure all PRN orders have specific instructions for staff including the order in which medications should be administered. Ongoing education will be provided to Medication Aides as needed based on findings of daily 24-hour (72-hours on Monday) audits. Physician orders will also be reviewed quarterly by RN and sent to provider for signature to provide coordination of care. 3. This system will be evaluated monthly as part of the facility continuous quality improvement process and will include a review of all MAR audits.   4. The Arbor Administrator and RN will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted every other month, included required components on fire drill records, and provided fire life safety instruction to staff on alternating months. Findings include, but are not limited to: On 06/27/22, fire drill and fire/life safety training records for the previous six months were requested. Review of the documentation provided identified the following: * Two fire drills had been completed during the six-month time frame reviewed; * Fire drill records lacked the following components: - Location of simulated fire origin; - Evacuation time-period needed; and - Number of occupants evacuated. * Fire and life safety instruction was not consistently provided to staff on alternate months. The requirements regarding fire drills, and fire and life safety instruction for staff were reviewed with Staff 1 (Administrator) on 06/27/22 at 3:00 pm. She acknowledged the findings.

1. A training was done with Maintenance Director that included a review of all required components related to the correct procedure for fire drills. All staff will be re-educated at next staff meeting on the fire drill procedure. 2. To prevent recurrance company fire drill form will be utilized and will be filled out completely, including all required components. Computer program used to document fire drills has been updated to include all required components as well as rotating schedule for locations and shifts. 3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance. 4. The Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to ensure residents received fire and life safety training within 24 hours of move in and annually. Findings include, but are not limited to: Fire and life safety records were requested during the survey. The following deficiencies were identified: * Documentation of fire and life safety training provided to residents within 24 hours of move in; and * Documentation of annual fire and life safety training provided to residents. The need to ensure residents received fire and life safety training within 24 hours of admission and re-instructed, at least annually, was discussed with Staff 1 (Administrator) on 06/29/22 at 10:25 am. She acknowledged the findings. No further information was provided.

1. Fire and life safety training has been completed and documented for all current residents. 2. To prevent recurrance, admission packet has been updated to include a form to document fire and life safety training within 24 hours of admission. Environmental evaluation, which is completed semi-annually for all residents was also updated to include documentation of re-instruction on fire and life safety training. 3. Fire drills and fire and life safety trainings will be reviewed monthly as part of our CQI process to ensure compliance. 4. The Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview it was determined the facility failed to ensure outdoor perimeter fencing was not secured in a way that prevented resident exit. Findings include, but are not limited to: Observation of the courtyard on 06/27/22 revealed the egress fencing gates were secured with keyed locks. Both gates had magnetic locking systems and/or keypads, but they were not functioning. The surveyor and Staff 4 (Maintenance Director) toured the courtyard the same day. He acknowledged the gates required a key to open them. He was unsure if the facility had written approval from the Department to lock the gates with a keyed lock. The courtyard was toured with Staff 1 (Administrator) on 06/28/22 at 9:00 am. She acknowledged the findings.

1. A meeting was held with city deputy fire marshal, state deputy fire marshal and city planner and it was determined that the fencing gates are not a fire egress. 2. Per the International Fire Code (Chapter 10: Means of Egress) and the state Fire Marshal, the community's two routes of egress are adequate for the size of the community. The courtyard gate is not considered one of the two routes of egress. 3. The Fire Marshal will continue to inspect the community every two years and ensure compliance with all fire codes. 4.  Community will change gate system to a magnetic key pad system for both gates.  This should be completed by October 15, 2022. 4. The Arbor Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean, in good repair and free from odors. Findings include, but are not limited to: Observations of the facility on 06/27/22 and 06/28/22 revealed the following: * Rooms 122, 123, 124, 125, 126, 127, 131, 132, 133, 135, 136, 137, 141, 143, 144, 145, 146, 147 and 150 had scraped doors and/or jambs; * The common activity room had gouged wall corners and a pillar, and a windowsill was missing paint and had an accumulation of dead bugs; * The common bathroom off of the activity room lacked toilet paper, had chunks of black matter in the sink, and scraped paint on the door frame; * An exterior door (next to the laundry room) had an accumulation of dirt and debris on the metal threshold. The window next to the door had chipped paint on the sill and an accumulation of dead bugs; * An exterior door near Room 127 had black matter on the metal threshold and dead bugs on the windowsill adjacent to the door; * A hallway near the dining room had eight screws protruding from the wall; * The common living room had stained furniture and scraped paint on the courtyard door; * The dining room had several walls and corners with gouged/scraped paint, peeling paint on the window sill, dirt and debris on the top of perimeter baseboards, dirt and debris inside cabinets and floor drain under the beverage station, food matter on the exterior of the trash can, and trash and food debris on the floor surrounding the trash can; and * Pervasive urine odors were noted in halls and common areas during the survey. The surveyor toured the environment with Staff 1 (Administrator) on 06/28/22. She acknowledged the findings.

1. A complete walkthrough of the community was completed and all areas needing cleaning and/or repair will be completed no later than 8/29/22. 2. To prevent recurrance, Maintenance Director will conduct a weekly walkthrough of the community and will identify any areas needing cleaning and/or repair. Weekly walkthrough will be reviewed at standup meeting and a plan will be put in place for any identified items. 3. Completion of weekly walkthrough tasks will be reviewed monthly as part of the community's CQI process. 4. The Arbor Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with alarms or other acceptable system to alert staff when residents exited the building. Findings include, but are not limited to: During a walk-through of the facility on 06/27/22, the exit door to the courtyard was found to have no working audible alarm or system in place to alert staff when a resident exited the building. The surveyor observed the door with Staff 1 (Administrator) on 06/28/22, and with Staff 4 (Maintenance Director) on 06/30/22. Both acknowledged the door did not have a working alarm or acceptable system to alert staff when a resident exited the building.

1. An audible alarm was added to the exit door to the courtyard. 2. Community is in the process of upgrading the emergency call system, which will also include a feature that will send a page to the direct care staff's pager alerting them when the door is opened. 3. The door alarm and emergency call system will be tested through TELS system monthly. 4. The Arbor Administrator, Executive Director and Maintenance Director are responsible for maintaining this system.

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: C 150, C 200, C 231, C 240, C 420, C 422, C 510, C 513 and C 555.

Refer to POC for C150, C200, C231, C240, C422, C510, C513, and C555

Based on observation, interview and record review, it was determined the facility failed to provide health care services in accordance with the licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 242, C 252, C 260, C 270, C 280, C 282, C 290, C 303, and C 310.

Refer to POC for C242, C252, C260, C270, C280, C290, C303, and C310

Based on observation, interview and record review, it was determined the facility failed to ensure individualized nutritional plans for each resident were developed and included in service plans for 2 of 5 sampled residents (#s 5 and 6). Findings include, but are not limited to: 1. Resident 6's current service plan was reviewed during survey and lacked an individualized nutrition and hydration plan based on his/her needs. The lack of an individualized nutritional plan was discussed with Staff 1 (Administrator) on 06/29/22 at 2:09 pm. She acknowledged the findings. 2. Resident 5 was admitted to the memory care facility in 04/2022 with diagnoses including Alzheimer's disease. Between 04/07/22 and 06/29/22, the resident experienced significant weight loss, required cuing and reminders to eat and to be provided finger foods to aide in eating.   The service plan, last updated 05/17/22, lacked information related to the resident's individual nutritional and hydration needs and current nutritional status, history of frequent urinary tract infections and increased caloric needs related to constant walking and pacing behaviors.   During the survey, it was observed the resident was not provided snacks consistently throughout the day, and was not encouraged to consume fluids regularly.   The need to develop individualized plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Administrator) and Staff 2 (RN) on 06/30/22. They acknowledged the findings.

1. Service Plans for residents #5 and 6 will be updated to reflect individualized nutrition and hydration plans based on their needs.  All residents' weights and diets have been reviewed.  All service plans will be reviewed for individualized nurtition and hydration plans.   2. To prevent recurrance, all current resident service plans will be audited for accuracy including nutrition and hydration plans.  Going forward all new residents will have an individualized nutrition and hydration plan included in their full service plan.   3. Nutrition and hydration portions of the service plans will be evaluated and reviewed upon move in, at 30 days, quarterly and as needed to ensure that they are reflective of current resident needs. 4. The Arbor Administrator and Executive Director will be responsible for maintaining this system.

Based on interview and record review, it was determined the facility failed to evaluate and develop individualized activity plans for 4 of 5 sampled residents (#s 1, 2, 5 and 6) whose activity plans were reviewed. Findings include, but are not limited to: Residents 1, 2, 5 and 6's records were reviewed during the survey. There was no documented evidence an activity evaluation had been completed and that service plans had been individualized to reflect the following: * Past and current interests; * Current abilities and skills; * Emotional/social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate in activities; and * Identified activities for behavioral interventions. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities. The need to ensure residents were evaluated and had an individualized activity plan was discussed with Staff 1 (Administrator) on 06/29/22 at 2:09 pm. She acknowledged the findings.

1. Individualized activity plans will be developed and service plans will be updated for all 4 sampled residents (1, 2, 5,and 6). 2. Community recently hired a new Life Enrichment Director for the Arbor, who will complete training on regulations related to activity programming for residents, including individualized activity plans. All resident activity profiles will be updated to include Individualized activity plans for all residents based on their activity preferences and needs.  Inservicing will occur with all care staff on the individualized activity packets available to them. 3. Monthly, as part of our CQI program, changes in activity levels will be reviewed and individualized activity plans will be adjusted as needed. Individualized activity plans will be evaluated with each evaluation/service plan review quarterly, or with significant change of condition. 4. The Arbor Administrator and Arbor Life Enrichment Director will be responsible for maintaining this system.

Based on observation, interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 1 of 2 sampled residents (#5) with documented behaviors. Findings include, but are not limited to: Resident 5 was admitted to the facility in 04/2022, with diagnoses including Alzheimer's disease. Resident 5's progress notes documented multiple incidents of behaviors including resident to resident physical altercations, elopement attempts, resistance to care, striking staff, disrobing in public, pacing and difficulty sleeping and eating. During an interviews on 06/28/22 and 06/29/22, direct care staff confirmed Resident 5 displayed the behaviors listed above. Staff reported they would re-direct the resident when s/he was displaying unsafe behaviors and provided cuing to eat meals. The resident's current service plan, last updated 05/17/22, included a description of the behaviors displayed by the resident. The interventions included the following: * escorting the resident to their room to help dress in appropriate clothing; * respect and acknowledge the resident's reality and avoid arguing or reasoning; * be alert to bowel and bladder patterns; * use a gentle voice and ensure the resident s/he is safe ...; * escort resident to a familiar area; * attempt to "joke" with him/her ...; * talk in a low toned voice and provide a diversional activity. On 05/23/22, a behavior support specialist completed an evaluation of the resident's behaviors and provided a behavior support plan (BSP). The plan included specific interventions to implement and monitor to address behaviors. Some of the interventions included: * possible causes of pacing behavior including memory loss, boredom, relieving pain, continuing a habit and looking for a person; * check to determine whether there are medication interactions; * address the sores/blisters on the resident's feet since pain may be a factor; * keep some personal items out where the resident can see them; * placing a large clock in the room to show the time of day; * address effort to relieve any pain or discomfort; * find ways to engage the resident to remain mentally and physically active, to play games or engage in hobbies, involve him/her in "housework"; * assist to wear socks in his/her shoes while walking; * provide snacks and drinks while walking to encourage eating; * implement the use of visual aids whenever possible; * provide foods that are colorful, smell good and are to his/her liking; * leave the bathroom door open and the light on to make the room more dementia friendly; and * avoid "correcting" him/her. The interventions in the BSP had not been incorporated into the resident's service plan and were not being implemented by staff during observations of the resident throughout the survey. On 06/30/22, the behaviors and BSP were reviewed with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the interventions on the BSP had not been incorporated into the service plan. Staff 1 stated the behavior support specialist would be providing a training to staff in the near future. The need to include an individualized behavior plan for residents with behavioral symptoms and coordinate the plan provided by outside consultants was discussed with Staff 1 and Staff 2 on 06/30/22. They acknowledged the findings.

1. The BSP interventions have been reveiwed and incorporated into resident 5's service plan.  All staff have reviewed updated SP and have been in-serviced on the interventions.   2. An audit of all residents with BSP's will be completed by LN and support staff.  Interventions will be incorporated and all staff will be in-serviced.  Quarterly audits of SPs and BSP's will be conducted to ensure that appropriate interventions are included.  All-staff training through the LMS will continue per regulatory guidelines and as needed. 3. Evaluations will occur at least quarterly during the SP review process and as needed when changes have been made by either the Behavior Support Specialist or facilty staff. 4. The Arbor Administrator, Executive Director and Maintenance Director will be responsible for maintaining this system.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to: Observations during the survey between 06/27/22 and 06/29/22 indicated the door to the courtyard was locked and did not allow residents to exit and return without staff assistance. Additionally, the interior of the door had large red lettering that stated the door was "NOT AN EXIT." During a tour of the building on 06/28/22 at 9:00 am with Staff 1 (Administrator), the door was locked. She acknowledged the door should have been unlocked. The surveyor also discussed that the signage indicating that the door was not an exit was a potential deterrent and might discourage residents to use the courtyard. The need to ensure residents had access to secured outdoor spaces without staff assistance or other deterrents was discussed during the exit conference on 06/30/22.

1. Signage indicating Not an Exit, was removed from patio door and door was unlocked.  All staff have been inserviced that the patio door should remain unlocked during waking hours of 6am to 8pm unless during inclement weather. 2. All staff in the Arbor have been inserviced on the regulation and the residents' rights to accessing the secured outdoor space. HCC's as part of shift tasks, will monitor door to ensure it is unlocked during waking hours and that it is secured during times of inclement weather as needed. 3. Monitoring will occur as part of the monthly CQI process. 4. Arbor Administrator and Executive Director will be responsible for monitoring and compliance.

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 resident rooms revealed multiple rooms were locked from the outside, preventing residents from entering their rooms without assistance from staff. Caregiving staff each carried a key which could open residents' rooms. On 06/27/22 and 06/29/22, Resident 5 was observed trying to open his/her apartment door and stated, "it's locked," and walked away. Resident 5's service plan did not address a preference for wanting the door locked. On 06/27/22, an unsampled resident was observed seeking out staff to unlock his/her door. During interviews with direct care staff on 06/28/22, staff stated they locked the apartment doors to prevent several residents from wandering into other resident's rooms. On 06/30/22, the need to ensure residents were not locked outside their rooms and to include the preference for a locked door in the service plan if the resident requested a locked door was discussed with with Staff 1 (Administrator) and Staff 2 (RN). They acknowledged the findings.

1. All resident apartment doors were unlocked unless resident's requested.  Residents who prefer to have their doors locked, will have this added to their service plan and staff will be inserviced. 2. Residents who's preference it is to have their door locked when out of the room, will have service plan updated. All other residents will have doors to apartments left unlocked.  All staff have been inserviced on locking doors. 3. Service plans will be reviewed quarterly to ensure that resident preference related to locked doors, is reflected.  Also will be part of the monthly CQI meeting.   4. Arbor Administrator and Executive Director are responsible for monitoring of compliance.

The findings of the relicensure survey, conducted 06/27/22 through 06/30/22, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with 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 first re-visit to the re-licensure survey of 06/30/22, conducted 10/24/22 through 10/25/22, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.