Timberwood Court Specialty Care Community

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

Based on observation and interview, it was determined the facility failed to ensure the environment was maintained in clean and good repair. Findings include, but are not limited to: Observations of the Maple and Oak memory care units, from 08/25/25 through 08/27/25, identified the following: * Significant carpet stains were observed throughout Maple and Oak cottages; and * There was a strong, pervasive urine odor detected in Oak cottage, which failed to dissipate over the course of the survey. On 08/27/25, the need to ensure the environment was maintained in clean and good repair was reviewed with Staff 1 (ED) and Staff 5 (Maintenance Services). They acknowledged the findings.

Deficiency:stained carpet and strong urine odor. Plan of correction 1. All community carpets were professionally cleaned with a odor nutralizer specific to urine on 8/28/2025. Areas with stains were treated with an acid wash on 8/28/2025. 2. Carpeting in all common areas on both Oak and Maple sides will be replaced to fully address the staining and odor. The community is currently accepting bids for carpet replacement. Once bid is selected , installation will occur within an estimated 10-12 weeks lead time. 3. Until the carpeting is replaced housekeeping supervisor will complete enviromental rounds to ensure the areas remain clean and odor free, this information will be shared with the Executive Director and any stains or odors will be addressed immediately. Carpets have been scheduled for twice monthly professional cleaning and application of odor nutralizer. These processess will ensure carpets remain clean and odor free and prevent reoccurrance of stain and odor concerns. 4. The Housekeeping Supervisor with oversight by the Executive Director will be responsible for ensuring corrections and completed and monitored.

OAR 411-054-0200 (4)(d-i) Doors, Walls, Elevators, Odors (d) INTERIOR DOORS. Lever-type door handles must be provided on all doors used by residents.(e) EXIT DOORS. Exit doors may not include locks that delay evacuation except as specified by the building codes. Such locks may not be installed except with written approval of the Department.(A) Exit doors may not include locks that prevent evacuation.(B) If an electronic code must be entered to use an exit door that code must be clearly posted for residents, visitors, and staff use.(f) WALLS AND CEILINGS. Walls and ceilings must be cleanable in kitchen, laundry, and bathing areas. Kitchen walls must be finished smooth per OAR 333-150-0000 (Food Sanitation Rules).(g) ELEVATORS. A RCF with residents on more than one floor must provide at least one elevator that meets Oregon Elevator Specialty Code (OESC) requirements.(h) The interior of the facility must be free from unpleasant odors.(i) All interior and exterior materials and surfaces (e.g., floors, walls, roofs, ceilings, windows, and furniture) and all equipment necessary for the health, safety, and comfort of the resident will be kept clean and in good repair.

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: C 513.

Deficiency:stained carpet and strong urine odor. Plan of correction 1. All community carpets were professionally cleaned with a odor nutralizer specific to urine on 8/28/2025. Areas with stains were treated with an acid wash on 8/28/2025. 2. Carpeting in all common areas on both Oak and Maple sides will be replaced to fully address the staining and odor. The community is currently accepting bids for carpet replacement. Once bid is selected , installation will occur within an estimated 10-12 weeks lead time. 3. Until the carpeting is replaced housekeeping supervisor will complete enviromental rounds to ensure the areas remain clean and odor free, this information will be shared with the Executive Director and any stains or odors will be addressed immediately. Carpets have been scheduled for twice monthly professional cleaning and application of odor nutralizer. These processess will ensure carpets remain clean and odor free and prevent reoccurrance of stain and odor concerns. 4. The Housekeeping Supervisor with oversight by the Executive Director will be responsible for ensuring corrections are completed and monitored.

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 interview and record review, conducted during a site visit on 05/21/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:    A review of the facility's ABST indicated the "minimum time needed based on acuity" for each segregated area was as follows: · Oak side: o Day shift: 3.55 care staff; o Swing shift: 3.18 care staff; and o Night shift: 1.54 care staff. · Maple side: o Day shift: 2.40 care staff; o Swing shift: 2.26 care staff; and o Night shift: 1.16 care staff.   A review of the facility's staff schedule dated 05/14/25 through 05/21/25 indicated the facility had been short-staffed to their ABST for every day. The facility had not scheduled two direct care staff at all times for residents who required the assistance of two direct care staff for scheduled and unscheduled needs.   An interview with Staff 1 (Executive Director) indicated that both segregated sides had residents who required multiple-person transfers.   It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on interview and record review, conducted during a site visit on 05/21/25, the facility's failure to fully implement and update an Acuity-Based Staffing Tool (ABST) was substantiated. Findings include, but are not limited to:    A review of the facility's ABST indicated the "minimum time needed based on acuity" for each segregated area was as follows: · Oak side: o Day shift: 3.55 care staff; o Swing shift: 3.18 care staff; and o Night shift: 1.54 care staff. · Maple side: o Day shift: 2.40 care staff; o Swing shift: 2.26 care staff; and o Night shift: 1.16 care staff.   A review of the facility's staff schedule dated 05/14/25 through 05/21/25 indicated the facility had been short-staffed to their ABST for every day. The facility had not scheduled two direct care staff at all times for residents who required the assistance of two direct care staff for scheduled and unscheduled needs.   An interview with Staff 1 (Executive Director) indicated that both segregated sides had residents who required multiple-person transfers.   It was determined the facility failed to fully implement and update an ABST. Findings were reviewed and acknowledged by Staff 1. An investigation determined a licensing violation had occurred.

Based on observation and interview, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:   Observation of the facility kitchen and unit kitchenettes were reviewed on 05/09/24 from 11:30 am through 3:00 pm and found the following:   a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, and/or black matter was visible on or underneath the following:   * Popcorn machine interior and kettle; * Maple and oak kitchenette drawers/cupboards; * Maple and oak kitchenette ovens and range top burners; * Kitchen drains; * Areas of ceiling in main kitchen; * Kitchen ceiling vents/light fixtures; * Countertop mixer; and * Exterior of meal delivery carts. b. The following areas were in need of repair:   * Main kitchen ceiling with peeling/chipped paint; * Drawers in units with exposed porous wood; and * Wood shelving under steam table with exposed porous wood. c. Interview with Staff 2 (Person in Charge) revealed inadequate knowledge in employee illnesses/symptoms that required exclusion. Staff 2 was not able to correctly identify all protein cook to temperatures. Staff 2 was not able to correctly discuss proper cooling processes. d. Multiple cutting boards and cutting surfaces were found heavily stained and scored. Multiple grill spatulas were found with handles damaged and no longer smooth cleanable surfaces and in need of replacement. Utility cart storing chemicals was rusted and non smooth/cleanable surface. e. Multiple food items in reach in fridges and freezers did not contain open dates or use by dates. One item in unit fridge was found past it's identified use by date (sliced cheese use by date: 5/7/24). f. Oak unit refrigerator did not have a thermometer to monitor cold food storage temperatures. Both Oak and Maple unit refrigerators storing resident food and drinks containing potentially hazardous food items did not have process where cold food temps were monitored by facility staff to ensure food items held at 41 degrees or below as required. Staff 1 (Executive Director) verified there was no current process to monitor the refrigerator temperatures. h. Maple kitchenette had single service items (spoons/straws) that were stored open to potential contamination with food contact surfaces exposed.   i. Staff 2 was observed washing dishes. Staff 2 did not undergo a hand wash step when going between washing dirty dishes to handling clean dishes. Staff 2 was also observed wiping clean sanitized dishes with a towel on the food contact surfaces to help them dry. This towel used to wipe the sanitized dishes was placed on the waist of Staff 2 and was exposed to potential dirty spray while washing dishes. At approximately 2:00 pm and 2:45 pm, surveyors reviewed above areas with Staff 2 (Dining Services Director), Staff 3 (Maintenance Director) and Staff 1 (Executive Director), who acknowledged the identified areas.

Providers plan of correction for the tag of C240 and memory care tag Z142 is as follows. A. Food debris, splatters, loose food, trash, dirt, dust and or black matter that was visable on the following areas has been cleaned and made in good repair. ~The popcorn machine has been cleaned and stored in an offsight location at this time. ~Maple and Oak kitchenette drawers and cupbaords have been wiped down and food debris removed. This task has been added to the nightly cleaning list for  care partners to complete nightly. This will be over seen each night by the supervisor on duty. ~Maple and Oak kitchenette ovens and burners are to have debris removed and cleaned nightly as needed to remove food debris and spills. This task has been added to the nightly cleaning task list and will be over seen nightly by the supervisor on duty. ~Kitchen drains have been cleaned and task added to weekly zonal cleaning for the kitchen cleaning. This will be monitored by the Dining Serviced Director. ~Areas in kitchen ceiling in main kitchen have been cleaned and patched and repainted. Cleaning of kitchen ceiling will be done monthly by maintenance director. ~Kitchen ceiling vents and light fixtures were taken down and cleaned and repainted. Maintenance director will check and clean monthly. ~Countertop mixer has been deep cleaned with food debris removed. A plastic dust cover was purchased and is in place while not in use to keep dust off the machine. Cleaning of this item has been added to the weekly zonal cleaning for this item. This will be overseen by the Dining Services Manager. ~Exterior of meal delivery cart was deep cleaned and debris was removed. This task has been added to the daily cleaning task list for the kitchen and will be overseen by the Dining Services Director. B.The following areas were in need of repair. ~Main Kitchen ceiling had peeling and chipped paint. The areas have been cleaned, sealed and repainted. Maintenance Director will observe ceiling monthly and repair any further areas as needed. ~Drawers in units with exposed porus wood and wood shelving under steam table has porus wood. This area has been repainted and a metal overlay has been ordered to prevent continued surface areas from being scraped, scratched and wood exposed as a porus surface. This metal is expected to be in the community 6/25/2024 and will be installed within 2 weeks after the metals arrives. This area will be inspected monhly to look for areas that have non cleanable surfaces by the Dining Services Director. C. Staff person was unable to demonstrate adaquate knowledge of employee illness and symptoms for exclusion. This director has printed the illness policy and each kitchen employee was given a copy and a signed copy was placed in each kitchen persons file. A copy of the illness policy was also made available in the kitchen area to reference. This policy is also available in the community guidebook. D. Multiple cutting boards and cutting surfaces were found heavily stained. New Cutting boards were ordered and are in place in the kitchen. Old stained cutting boards have been removed from the community. Dining Services Manager will inspect items monthly and order new items as these become stained or not have a cleanable surface area.   ~Multiple grill spatulas were damaged and no longer had smooth cleanable surfaces. These items were removed from the kitchen and replaced with brand new spatulas. Dining Services Manager will inspect items monthly or as needed and replace or repair items when surface no longer cleanable or become porus. ~utility cart that was storing chemicals was rusted and not a smooth cleanable surface. Cart was removed from the premises and chemicals are now stored in a different location. E. Multiple food items in fridges and freezers did not contain open or use by dates. The task of dating items will be done as items are opened and used. It will be overseen each day by the cook on duty. F. Oak and Maple fridges did not have cold food thermometers where food temps could be monitored daily. Fridge thermometers were purchased for both fridges and are in place in each fridge. The task of monitoring the temps was placed in the ECP system and will be done daily by the med techs. H. Maple kitchenette had single serve spoons and straws that were stored open. Straw and spoon dispensers were purchased and are in place in both kitchenettes. These items will be replaced as needed. I. Staff was observed washing dishes and not washing hands when going between dirty and clean dishes. The staff was also observed using a dish towel to wipe the surface of a sanitized dish after it had been on the waist of a staff member. Kitchen inservice has been scheduled for June 25th and the topic of proper sanitation and dish washing will be taught again. The regional Dining Services Director will oversee this class.

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 C 240.

see C 240

The findings of the kitchen inspection, conducted 05/09/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the revisit to the kitchen inspection of 05/09/24, conducted 07/18/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation, record review 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 areas, food preparation, and food service on 5/17/23 revealed splatters, spills, drips, dust and debris noted on: - Can opener blade and casing; - Small table top mixer; - Interior of drawer next to steam table holding hamburger buns; - Grill/Oven/stove knobs; and - Vents, fire sprinklers, and parts of ceiling with dust accumulation. The following items/areas in the main kitchen were in need of repair: - Corner of steam table area with plastic covering broken and pieces missing as well as areas of laminate surface chipped and missing exposing wood surface; - Cabinets/shelves under steam table had multiple areas where wood was exposed; - Ceiling around vent in dry storage in need of repair; - Clock was broken with a large piece of plastic missing; and - Multiple vents with rust build up. * Slicer was observed to be uncovered and was not protected from potential contamination when not in use/stored. * Cutting board on steam table was observed heavily scored and/or stained. * Facility did not have a small diameter thermometer to accurately check/monitor temperatures of thin foods. * Ice machine was found with large amount of mold type substance on the interior of the machine where ice was made. Facility was instructed to discard the ice and clean the ice machine immediately. Staff 3 (Maintenance Services Director) was interviewed and stated he did service the machine and cleaned all areas every 6 months. He did indicate that in-between his regular servicing of the machine the dietary department was responsible for cleaning the machine.   * Ware washing machine rinse cycle temperature was not reaching the required temperature of 180 degrees Fahrenheit as required for effective sanitization of dishes. Multiple observations during survey rinse temperatures ranged from 161-164 degrees F. Staff 2 (Executive Chef/Person in Charge) stated that the temperature of the final rinse had been at around 160 degrees F since they recently switched over to a new type of soap. Staff 3 was not aware that the temperature was not reaching 180 degrees F. The data plate on the machine confirmed the final rinse temperature needed to be 180 or higher for sanitization. Upon evaluating the machine, Staff 3 indicated a valve in the machine had failed and most likely was the cause of the temperature not reaching correct levels. The facility stated it would be sanitizing all dishes with 3 compartment method until the machine could be fixed by an outside vendor. * Meal service was observed and there were multiple observations of kitchen staff using single service gloves incorrectly. There were multiple times where the staff had handled RTE (ready to eat) food items with gloves that were potentially contaminated from other tasks/items. One staff was observed to use gloved hands to serve food items (cooked carrots and potato wedges) not using utensils. Staff members gloves were contaminated by touching cooler door handles, meal delivery carts, rolling up his sleeves, and wiping gloved hands on his pants. Another staff was observed to touch BBQ sandwiches and tomato slices after touching cooler door handle and meal delivery carts with the same gloved hands. Staff 2 toured kitchen with surveyor. At approximately 12:15 pm surveyor reviewed areas above with Staff 2. Staff 2 acknowledged the above findings. At 12:30 pm the areas in need of cleaning, repair and attention were reviewed with Staff 1 (Executive Director). She acknowledged the findings.

Community acknowledges that Facility areas were not maintained in occordance with the Food Sanitation rules and have been addressed as described below. , Kitchen cleaning list has been updated and posted for daily, weekly and monthly cleaning duties. Each person will sign off on cleaning duties completed and Executive Chef will audit cleaning schedule weekly.   1. Areas of kitchen food starage, food prep and food service  revealed splatters, spills, drips, dust and debris ~Can opener and casing, Can opener was replaced with new equipment. Equipment is scheduled to arrive on 6/10/2023 and will be installled my building maintainence and will be cleaned daily by kitchen staff on duty. 2. small table top mixer Mixer cover has been ordered and will be here on or about 5/8/2023 and will be used to cover mixer when not in use. Kitchen staff will ensure that mixer is cleaned as needed and after every use and covered when not in use. 3. Interior drawer next to steam table that holds the hambuger buns. Debris was removed from kitchen drawer on 5/17/2023. Kitchen staff to wipe out drawer after each meal or as needed to prevent crumbs or debris from building up in drawer. This taskadded to daily cleaning schedule by kitchen staff 4.Grill/oven/stove knobs and Vents, Fire sprinklers and parts of ceiling fan with dust accumulation. Kitchen staff to remove items from the stove daily and clean and remove debris and dust per cleaning schedule daily. Vents, ceiling fan and fire system being cleaned by fire company on 6/23/2023 to remove the dust and grease build. Community setup routine cleaning with fire company for 1x each quarter.

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 C 240.

5.Corner of steam table area with plastic covering broken and pieces missing as welll as areas of laminate surface chipped and missing exposing wood surface. Broken pieces were removed and replaced with new plastice pieces. Exposed wood was cleaned and repaired with fresh paint 6/12/2023    Cabinets with exposed wood were repainted by 6/12/2023 ensuring clean surfaces with no exposed wood 6.Ceiling around vent in dry storage in need or repair Ceiling area and vent was cleaned and repainted on 6/2/2023 by building maintenance. 7.Clock was broken with large plastic piece missing and Multiple vents with rust buildup. Clock was replaced with new clock on 6/2/2023, vents were moved cleaned and replaced with a fresh coat of paint on 6/2/2023 8. Slicer was observed to be uncovered and was not protected from potential contamination while not in use. Slicer cover was ordered and is scheduled to be here about 6/23/2023. Staff using clean dry palstic bags until new cover gets here. Staff to ensure slicer is santitzed as needed and ensure cover is in place when not in use. 9. Cutting board on steam table was observed heavily soiled scored and stained. Community will use bleach solution to wash and sanitize daily and as needed to ensure it is clean.Completed and as needed by 6/1/2023 10.Facility did not have small diameter thermometer to accurately check or monitor temperatures of thin foods. Community ordered and received small thermometers  on 05/22/2023   11.Ice machine was found with large amount of mold type substance. Facility was instructed while surveyor was still in the building to empty the ice machine and service. Ice machine was promptly emptied and cleaned and weekly cleaning has been added to cleaning schedule. Kitchen staff will ensure this gets done weekly.Ice machine will also be serviced every 6 months by maintenance director 12.Ware washing machine was not reaching temp of 180 degrees for effective sanitation Machine continued to not temp after maintenance supervisior checked it. Kitchen staff were instructed to do sanitation in the 3 compartment sink until it could be fixed. Machine tech determined thermostat was bad and part has been ordered. Machine is temped daily by kitchen staff and if machine does not temp out to 180, maintenance is called and 3 sink sanitation is implemented. 13.Meal service was observed and kitchen staff were using single service gloves incorrectly. Kitchen staff have a training on 6/26/2023 to be retrained on handling food items with gloves and how to prevent cross contamination

The findings of the kitchen inspection, conducted 5/17/23, 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 05/17/23, conducted 07/21/23, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on interview and record review it was confirmed the facility failed to exercise reasonable precautions against any condition that may threaten the health, safety, or welfare of the residents. Findings include: During separate interviews on 11/30/2022, both Staff #1 (S1) and Staff #4 (S4) stated that on 10/24/2022 Staff #7 (S7) did bring their infant child into work while on shift. S1 stated that they gave S7 permission to have the child in the medication room for a couple hours until S7 found someone to watch the child. A review of the job description of the medication technician and the facility's form of communication to all staff called Voicefriend. The Voicefriend indicates that a message was sent to the staff on 10/26/2022 stating, " Good morning, I wanted to reach out to all of you and let you know that the State of Oregon has notified us children are not allowed to come to work with you. If you are on the clock your child must not be here in the building. This goes for staff meetings as well. If you need help finding daycare, please let me know as there are a lot of resources out there and I can put you in touch with those resources." On 11/30/2022, these findings were reviewed and acknowledged by S1. Plan of Correction: S1 stated after being notified this was not acceptable to have staff members children in the facility during their shift, they pulled S7 off the floor and sent them home. S1 sent a memo through Voicefriend to all the staff to inform the staff.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 11/30/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review, it was confirmed the facility failed to carry out medications as prescribed. Findings include: Compliance Specialist (CS) reviewed Resident #1 (R1) and Resident #2 (R2) medication administration records (MARs) and progress notes for July 2022 as well as the facilities policy and procedures for medication errors. CS identified that on 7/25/2022 R1 was given R2 ' s medication. A same day incident report and proper notifications were made. The medication error was followed by alert charting for R1. Interviews on 8/4/2022 with Staff #1-3 were aware of the medication error. The facility proceeded to investigate, notify physicians, obtain new written orders as needed, created individual service plan, and notified local adult protective services Verbal Plan of Correction: The facility documented the incident, filled out a med error report and followed up per their policy and procedure. Training was provided to med tech and the medication cups are now being labeled with more information to easily identify correct resident.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes.  This report reflects the findings of the complaint investigation conducted 08/04/2022.  The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57.  The following deficiencies were identified: Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar cc: cubic centimeter CG: caregiver cm: centimeter F: Fahrenheit HH: Home Health HS or hs: hour of sleep LPN: Licensed Practical Nurse MA: Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter O2 sats: oxygen saturation in the blood OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day RN: Registered Nurse SP: service plan TAR: Treatment Administration Record tid: three times a day

Based on interview and record review, it was determined the facility failed to ensure falls with injury, injuries of unknown cause, and resident to resident altercations were promptly investigated to rule out abuse and reported to the local SPD office as required for 1 of 3 sampled residents (#2) whose incidents were reviewed. Findings include, but are not limited to: Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia and paranoid delusions. The resident's service plan dated 12/02/21 and interviews with care staff between 02/07/22 and 02/08/22 indicated the resident could ambulate on his/her own and utilized a walker. The resident was unable to consistently direct his/her own care, had a history of falls, and aggression towards others. Review of incident investigations and progress notes from 11/09/21 through 02/07/22 showed the following: * A progress note dated 11/16/21 indicated a bruise to the resident's mid back was found without a cause indicated. An investigation dated 11/16/21 was started but was not completed. * A progress note dated 11/25/21 indicated the resident experienced a fall, hit his/her face and had a red area under the right eye. An investigation dated 11/25/21 was started but was not completed. * A progress note dated 12/08/21 and 12/09/21 indicated the resident was on alert for an injury fall on 12/07/21. A bruise to the right buttock was noted. No investigation of the incident was completed. * A progress note dated 12/22/21 indicated the resident was found on the footrest of his/her recliner with the chair tipped. The resident had a reddened area and scrapes noted to the back. No investigation of the incident was completed. * A progress note 12/22/21 indicated Resident 2 was entering multiple resident rooms and "flashing" residents. Resident 2 entered a resident's room, "pulled [his/her] pants and depends down and bent/squatted over to show privates." Resident 2 was found naked in another resident's room and attempted to strike and pull down care staff who offered assistance. An investigation of the incident was started but was not completed and the incident was not reported to the the local SPD office. * A progress note dated 12/06/21 indicated the resident self reported s/he had fallen and "cracked head open." There was no sign of injury. No investigation of the incident was completed. * Progress notes dated 12/09/21 and 12/31/21 indicated the resident experienced non injury falls. No investigations was completed for either fall. The need to ensure resident incidents were promptly investigated to rule out abuse and neglect and reported when required was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. The staff acknowledged the findings. The facility reported the requested incidents involving injuries and exposed genitals to the local SPD office on 02/08/22. Confirmation of the reports were provided prior to survey exit.

Community acknowledged incomplete investigations and lack of reporting for incidents that met reporting criteria for Resident #2 for the dates in question (11/16/2021, 11/25/2021, 12/6/2021, 12/7/2021, 12/9/2021, 12/22/2021 and 12/31/2021). Community completed required reporting prior to survey exit on 2/8/2022. Community to conduct in-service training with staff on Abuse Reporting and Investigation Guidelines for Providers by March 31, 2022. Executive Director and/or Designee will be responsible for conducting investigations and meeting reporting requirements on an ongoing basis. Random compliance audits will be conducted by regional team (VPO and/or Nurse Consultant) on a bi-annual basis.

2. Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia. Observations of the resident and interviews with staff from 02/07/22 to 02/08/22 and review of the service plan dated 12/02/21, 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: * Dressing, repeated clothing changes and current sleep schedule; * Toileting assistance, incontinence care and toileting in inappropriate areas; * Psychotropic use; * Grooming related to facial hair; * Meal assistance, health shakes and fluid needs; and * Falls and safety interventions including fall mat. The need to ensure resident service plans were reflective of current care needs, provided direction to staff and were followed was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' current needs and status, provided clear direction to staff regarding the delivery of services, were followed and updated quarterly for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in June 2021 with diagnoses including dementia, diabetes and was receiving hospice services. a. Review of Resident 1's 09/26/21 service plan, current MAR, progress notes dated 11/12/21 through 02/07/22, observations of the resident and interviews with staff revealed the service plan was not reflective in the following areas: * Anti Coagulation therapy; * Turning every two hours; and * Mouth swab and ointment to lips every two hours. b. The last update of the service plan occurred on 09/26/21, not quarterly as required. The need to ensure service plans were reflective of the resident's current status and care needs and were updated quarterly was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 02/08/22. They acknowledged the findings. 3. Resident 4 was admitted to the facility in September 2021 with diagnoses including dementia and COPD. Review of Resident 4's 12/19/21 service plan, progress notes 11/12/21 through 02/07/22, observations of the resident and interviews with staff identified the service plan was not reflective of assistance needed in transferring the resident. On 02/08/22, the need to ensure service plans were reflective of the resident's current status and care needs was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

1. What actions will be taken to correct the rule violation for each example/resident? Resident #1: Upon further record review resident did have service plan completed in computer system on 12/25/2021 which meets the quarterly requirement; however, was not reviewed signed and completed by responsible party/resident and community and did not contain items listed in citation.   Resident #1 will have review of service plan and update to reflect current care needs (such as Anti-coagulant therapy, turning and positioning, oral care and use of lip ointment) and completed by 3/31/2022. Resident #2 will have review of service plan and update to reflect current care needs (such as Dressing with repeated clothing changes, sleep schedule, toileting assistance, incontinent care, and toileting in inappropriate places, use of psychotropic medication, grooming of facial hair, meal assistance, health shakes, fluid needs, fall and safety interventions to include fall mat)  and completed by 3/31/2022. Resident #4 will have review of service plan and update to reflect current care needs (such as assistance needed with transfers) and completed by 3/31/2022. All Resident's services plans will be reviewed, with ISP or handwritten changes that are initial and dated implemented for any care needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). ED, RCC and HSD will be re-educated on completed timely and comprehensive service plans by VPO or Nurse Consultant by 3/1/2022. Staff to be educated on utilization of service plans for providing care by 4/1/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the Resident current care needs on an ongoing basis.   Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Based on interview and record review, it was determined the facility failed to ensure service plans were developed by a Service Planning Team that consisted of the resident, the resident's legal representative if applicable, any person of the residents choice, the facility administrator or designee, and at least one other staff person who was familiar with or provided services, for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed.  Findings include, but are not limited to: Resident 1, 2, 3 and 4's most recent service plans lacked evidence that a Service Planning Team reviewed and participated in the development of the service plans. On 02/08/22, the need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #1,2,3 & 4 will have service plans reviewed by Service Plan Team that will consist of the following members at a minimum: Executive Director, Health Service Director, Resident Care Coordinator, Lifestyles Director, Resident/Responsible Party will be invited to attend and participate as part of this team.  Other team member will be included on a Resident-by-Resident basis to include: Caseworker, Hospice, and other Third-Party Providers as appropriate. Executive Director and/or HSD will oversee compliance by reviewing Service Plans prior to locking.

Based on observation, interview and record review, it was determined the facility failed to coordinate care with outside providers and ensure documentation of visits were maintained in the residents' records for 1 of 2 sampled residents (#2) who were receiving home health services from outside providers. Findings include, but are not limited to: Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia. During the review of the resident's record it was determined the resident received outside provider services related to Physical Therapy (PT). Observations of the resident, interviews with staff, and review of outside provider notes and progress notes from 11/09/21 through 01/26/22 were completed. The resident was admitted to PT services on 12/13/21 for strengthening and ambulation. PT visits were to occur once a week for six weeks. PT visit notes were not consistently documented. Two notes were documented between 12/13/21 and 01/26/22 when the resident was discharged from PT services. The need to ensure on-going coordination of care was maintained, documented and recommendations were implemented was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director) on 02/08/22. They acknowledged the findings.

idents # 1 & 2 will have outside provide records requested and reviewed. Any recommendations not currently implemented will be initiated and documented within medical record by 3/31/2022.   HSD and/or ED will meet with current outside providers to review protocol for exchange of information and coordination of care.   Staff will be provided additional education on coordination of care with outside providers by 3/31/2022. Review of outside provider documentation will be conducted weekly during High-Risk Resident Meeting with follow-up by HSD/RCC as needed.   Random chart audit for coordination of care will be conducted during QA process by Health Service Team.

Based on interview and record review, it was determined the facility failed to ensure signed provider orders were documented in the resident's record for all medications for 1 of 4 sampled residents (#4) whose orders were reviewed. Findings include, but are not limited to: Resident 4's physician orders and the 01/01/22 through 02/07/22 MAR were reviewed during survey. Resident 4's MAR indicated that s/he was receiving sertraline (for depression) 50 mg by mouth once daily. There were no signed physician order for this medication found in the resident record. On 02/09/22, the need to ensure signed provider orders were documented in the resident's record for all medications was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #4 order for Sertraline 50 mg was received from the pharmacy prior to survey exit on 2/8/2022.  All Resident MARs reviewed and compared to current orders to ensure signed orders are in-house conducted and completed by 3/15/2022.   Re-education for medication technicians regarding process for verifying medication orders prior to administration. Verification of order validation process by RCC/HSD and re-education to be completed by Nurse Consultant.  All Re-education to be completed by 3/31/2022. Monthly Sample of 5-10% of Resident for MAR to Order audits by Health Service Department and quarterly pharmacy consultant reviews for QA purposes.

Based on interview and record review, it was determined the facility failed to ensure staff documented non-pharmacological interventions that were attempted with ineffective results prior to administering PRN psychotropic medications, common side effects, and when to contact a health professional regarding side effects for 1 of 3 sampled residents (#4) who was prescribed PRN medications. Findings include, but are not limited to: Resident 4 was admitted to the facility in September of 2021. Resident 4 had a physician's order for Alprazolam 0.25 mg as needed for anxiety and agitation. Resident 4's 01/01/22 through 02/07/22 MAR indicated the resident was administered Alprazolam on 11 separate occasions. There was no documented evidence staff had attempted non-drug interventions with ineffective results prior to administering the psychotropic medication. There was also no documented evidence in the resident's record related to possible side effects of the medication. On 02/08/22, the need to attempt non-drug interventions prior to administering PRN psychotropic medications and documentation of side effects related to specific psychotropic medications was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident # 4 MAR will be updated to reflect need for documentation of non-drug interventions prior to administration of PRN Psychotropic Medications and service plan to address potential side effect monitoring.   All Residents all PRN Psychotropic Medications will be reviewed to ensure their MAR reflects non-drug intervention utilization prior to administration and service plans are reflective as side effect monitoring by 4/8/2022.   Med Techs will be re-educated on psychotropic medications, non-drug interventions, documentation and EMAR set-up and utilization for these processes.   HSD/RCC to oversee the compliance with documentation and implementation of ISPs/Service Plans for side effect monitoring.   HSD or Designee to oversee compliance with by MAR audits quarterly.

Based on observation and interview, it was determined the facility failed to keep all interior materials and surfaces clean and in good repair. Findings include, but are not limited to: A tour of the facility on 02/07/22 showed the following areas needed cleaning and/or repair: * Concrete floor behind industrial washing machine in main laundry room had several large cracks, up to one and a half inches wide, and an accumulation of dirt and stains; * Top surface of industrial washing machine, as well as connected tubing and venting surfaces were coated in white powder and dust; * Linoleum flooring seam in main laundry room was separated, approximately 18 inches long and half an inch wide; * Ceiling and walls in main laundry room had multiple areas of chipped paint, creating uncleanable surfaces; * Utility sink in main laundry room was coated with speckled black debris, as well as gray, yellow and brown splatters; * Doors and door jambs throughout Oak and Maple units had chipped paint and black streaks; * Quarter round floor moldings in Oak dining room were loose and pulled away in multiple spots; and * Built-in bookcases in activity areas in Oak and Maple units had splatters, streaks and chipped paint. The environment was toured with Staff 1 (Executive Director) and Staff 6 (Environmental Services Director) on 02/08/22. They acknowledged the findings.

The following areas have been address as described below: o The floor in the laundry room is being replaced all supplies have been ordered with an estimated delivery date of 4/2/2022.  Instillation has not been scheduled pending an exact delivery date.  Areas will continue to be cleaned to the best of the communities ability until replacement is finished.   o The laundry room had sheetrock replaced and areas   re-puttied, re-painted, to repair the walls. Area cleaned and cracks sealed by 4/9/2022 o Top surface of industrial washing machine, as well as connected tubing and venting surfaces were coated in white powder and dust Washing Machine cleaned, tubing replaced, and vent areas cleaned by 4/9/2022 o Ceiling in main laundry room had multiple areas of chipped paint, creating uncleanable surfaces Area repainted and cleaned by 3/15/2022 o Utility sink in main laundry room was coated with speckled black debris, as well as gray, yellow and brown splatters Sink cleaned, and debris and splatters removed by 3/1/2022 o Doors and door jambs throughout Oak and Maple units had chipped paint and black streaks Doors and door jambs throughout Oak and Maple cleaned and repainted as needed by 4/9/2022. o Quarter round floor moldings in Oak dining room were loose and pulled away in multiple spots.  Floor molding repaired and where unable to be repaired was replaced by 4/9/2022 o Built-in bookcases in activity areas in Oak and Maple units had splatters, streaks and chipped paint. Built-in bookcases in activity areas in Oak and Maple cleaned with splatters/streaks removed and chipped paint areas touched up. All areas above added to Preventative Maintenance Plan and routine housekeeping schedules. ED and ESD to conduct routine community physical plant inspections at least monthly to check for areas needing repairs/replacements.

Based on observation, interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to: Refer to C 231 and C 513.

Refer to POC for C231 and C513

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 260, C 262, C 290, C 303 and C 330.

Refer to POC for C 260, C 262, C 290, C 303 and C 330.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan for each resident was developed and included in the service plan for 2 of 4 sampled residents (#1 and 4) whose service plans were reviewed. Findings include, but are not limited to: Residents 1 and 4's current service plans were reviewed during survey. The service plans lacked information and staff instructions related to individualized nutrition and hydration status and needs. The need to develop individualized service plans addressing residents' nutrition and hydration needs was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director) and Staff 4 (Resident Care Coordinator) on 02/08/22. They acknowledged the findings.

Residents # 1 & #4 will have service plans updated to reflect hydration needs. Residents with specialized hydration needs will have services plans reviewed, with ISP or handwritten changes that are initial and dated implemented for any hydration needs not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on hydration and inclusion of specialized hydration needs in service plans by 4/1/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the Specialized Hydration needs (as needed) on an ongoing basis.   Random SP audits to be conducted by Health Service Department during QA process at least monthly.

Based on observation, interview and record review, it was determined the facility failed to consistently provide meaningful activities for all residents that promoted or helped sustain the physical and emotional well-being of the resident, and failed to ensure an individualized activity plan was developed for each resident based on their activity evaluation, for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to: Resident 1, 2 and 4's service plans offered some information about the residents' interests, but the facility had not fully evaluated the residents': * Current abilities and skills; * Emotional and social needs and patterns; * Physical abilities and limitations; * Adaptations necessary for the resident to participate; and * Activities that could be used as behavioral interventions, if necessary. Observations on 02/07/22 and 02/08/22 showed multiple residents wandering the halls, some calling out and residents seated in the TV area for extended periods of time without consistent interaction or intervention from staff. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the residents with more individualized activities. The need to ensure all residents had individualized activity plans developed and implemented to engage them in meaningful activities was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director). The staff acknowledged the findings.

Residents # 1, #2 & #4 will have service plans updated to reflect individualized activity plans. Residents will have the following areas evaluated with each comprehensive evaluation: Current abilities and skills; Emotional and social needs and patterns; Physical abilities and limitations; Adaptations necessary for the resident to participate; and Activities that could be used as behavioral interventions. Individualized Activity Plans to be developed in the Service Plan for each resident.   Current residents will be reviewed and an  ISP or handwritten changes that are initial and dated implemented for individualized activity plans not addressed in service plan by 4/8/2022. Changes to be fully incorporated into service plan with next comprehensive service plan (quarterly or change in condition). Staff to be educated on individualized activity plans and utilization of these plans by 4/1/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized activity plan on an ongoing basis.   Random SP audits to be conducted by Lifestyles Director for QA process at least monthly.

Based on interview and record review, it was determined the facility failed to provide an individualized service plan for behavioral symptoms that negatively impacted the resident or others in the community for 2 of 2 sampled residents (#s 2 and 4) with documented behaviors. Findings include, but are not limited to: 1. Resident 2 was admitted to the facility in November 2021 with diagnoses including dementia and paranoid delusions. Resident 2's record documented behaviors including anxiety, exit seeking, yelling, hitting staff, disrobing, hallucinations and aggression towards other residents including hitting and grabbing. The resident's service plan, dated 12/02/21, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 02/08/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director) and Staff 2 (Health Services Director). The staff acknowledged the findings. 2. Resident 4 was admitted to the facility in September 2021 with diagnoses including dementia. Resident 4's record documented behaviors including anxiety, throwing themselves onto the floor, refusing care, hallucinations, and aggressive behaviors towards other residents and staff including yelling and threats. The resident's service plan, dated 12/19/21, did not address the behaviors and/or lacked individualized interventions to assist staff in minimizing the negative impact of the behaviors. On 02/08/22 the need to develop individualized behavior plans for residents with behavioral symptoms was discussed with Staff 1 (Executive Director), Staff 2 (Health Services Director), and Staff 4 (Resident Care Coordinator). They acknowledged the findings.

Resident #2 Service Plan will be updated to reflect Behaviors to include: anxiety, exit seeking, yelling, hitting staff, disrobing, hallucinations and aggression towards other residents including hitting and grabbing and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022. Resident #4 Service Plan will be updated to reflect behaviors to include: anxiety, throwing themselves onto the floor, refusing care, hallucinations, and aggressive behaviors towards other residents and staff including yelling and threats and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 3/31/2022. Other Residents with known behaviors will have service plans reviewed and updated as needed to reflect behaviors and individualized interventions to minimize or mitigate the potential negative outcome from these behaviors by 4/8/2022. Staff to be provided education on utilization of service plans for minimizing and/or mitigation strategies for behaviors by 3/31/2022. ED and/or HSD to review service plans prior to locking to ensure they reflect the individualized intervention for behaviors on an ongoing basis.  Random SP audits to be conducted by Health Service Team for QA process at least monthly.

The findings of the re-licensure survey conducted 02/07/22 through 02/08/22 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations. Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document: ADL: activities of daily living bid: twice a day CBG: capillary blood glucose or blood sugar CG: caregiver cm: centimeter ED: Executive Director F: Fahrenheit HH: Home Health LPN: Licensed Practical Nurse MA:          Medication Aide MAR: Medication Administration Record MCC Memory Care Community mg: milligram ml: milliliter MT: Medication Technician OT: Occupational Therapist PT: Physical Therapist PRN: as needed qd: every day or daily qid: four times a day QI:     quality improvement RCC:       Resident Care Coordinator RN:     Registered Nurse TAR:     Treatment Administration Record tid:           three times a day

The findings of the re-visit to the re-licensure survey of 02/08/22, conducted on 06/02/22 through 06/03/22, 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 Home and Community Based Services Regulations OARs 411 Division 004.