Bayberry Commons Memory Care

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause were reported to the local Seniors and People with Disability (SPD) office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the injury was not the result of abuse for 2 of 2 sampled residents (#s 1 and 2) whose incidents were reviewed. Findings include, but are not limited to:

1. Resident 1 was admitted to the facility in 2021 with diagnoses including dementia.

Resident 1’s service plan, dated 07/17/25, noted the resident was dependent on staff for ADL care and was identified to be at risk for falls.

Progress notes reviewed between 06/05/25 through 08/26/25 noted the following:

* 06/19/25 - “…resident had a quarter sized bruise on the back of [his/her] upper thigh.”

On 08/27/25 at 9:16 am, an interview with the resident was attempted. Resident 1 “was not able to respond to surveyor questions.”

There was no documented evidence of an investigation of the injury of unknown cause to rule out abuse.

The facility was instructed to report the injury of unknown cause to the local SPD office. Investigation of the injury of unknown cause was completed on 08/28/25 at request of the surveyor. The completed investigation reasonably ruled out abuse.

The need to ensure all injuries of unknown cause were reported to the local SPD office as suspected abuse, unless an immediate facility investigation reasonably concluded and documented the physical injury was not the result of abuse, was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN) on 08/28/25 at 3:12 pm. Staff acknowledged the findings.

2. Resident 2 moved into the community in 10/2021 with diagnoses including dementia and hypothyroidism.

The resident’s 06/03/25 through 08/27/25 progress notes and incident reports were reviewed. The following was identified:

A 08/06/25 progress note documented, “Quarter-sized bruise to right forearm is noted. It is dark purple on the outside with a reddened center.”

There was no documented evidence that the injury of unknown cause was immediately investigated to rule out abuse.

During an interview at 11:20 am on 08/28/25, Staff 2 (MC Wellness Manager/LPN) confirmed the above injury lacked an investigation and had not been reported to the local Seniors and People with Disabilities (SPD) office. The surveyor requested the above injury be reported to the local SPD office, and confirmation was received at 12:20 pm on 08/28/25.

The need to report injuries of unknown cause to the local SPD office unless an immediate investigation reasonably ruled out abuse was discussed with Staff 1 (ED), Staff 2, Staff 13 (Regional RN), and Witness 1 (Nurse Consultant) on 08/28/25. They acknowledged the findings.

OAR 411-054-0028 (1-3) Reporting & Investigating Abuse-Other Action

(Amended 12/15/21)(1) The facility must have policies and procedures in place to assure the prevention and appropriate response to any incident. In the case of incidents of abuse, suspected abuse, or injury of unknown cause, policies and procedures must follow the requirements outlined below. In the case of incidents that are not abuse or injuries of unknown cause where abuse has been ruled out, the facility must have policies and procedures in place to respond appropriately, which may include such things as re-assessment, monitoring, or medication review. (2) ABUSE REPORTING. Abuse is prohibited. The facility employees, agents and licensee must not permit, aid, or engage in abuse of residents who are under their care. (a) STAFF REPORTING. All facility employees are required to immediately report abuse and suspected abuse to the local SPD office, or the local AAA, the facility administrator, or to the facility administrator's designee. (b) FACILITY REPORTING. The facility administrator, or designee, must immediately notify the local SPD office, or the local AAA, of any incident of abuse or suspected abuse, including events overheard or witnessed by observation. (c) LAW ENFORCEMENT AGENCY. The local law enforcement agency must be called first when the suspected abuse is believed to be a crime (e.g., rape, murder, assault, burglary, kidnapping, theft of controlled substances, etc.). (d) INJURY OF UNKNOWN CAUSE. Physical injury of unknown cause must be reported to the local SPD office, or the local AAA, as suspected abuse, unless an immediate facility investigation reasonably concludes and documents that the physical injury is not the result of abuse. (3) FACILITY INVESTIGATION. In addition to immediately reporting abuse or suspected abuse to SPD, AAA, or the law enforcement agency, the facility must promptly investigate all reports of abuse and suspected abuse and take measures necessary to protect residents and prevent the reoccurrence of abuse. Investigation of suspected abuse must document: (a) Time, date, place and individuals present; (b) Description of the event as reported; (c) Response of staff at the time of the event; (d) Follow-up action; and (e) Administrator's review.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure short-term changes of condition had documented weekly progress noted to resolution for 1 of 2 sampled residents (#1) who experienced changes of condition. Findings include, but are not limited to:

Resident 1 was admitted to the facility in 2021 with diagnoses including dementia.

Resident 1’s service plan, dated 07/17/25, noted the resident was dependent on staff for ADL care, received hospice services, and was identified to be at risk for falls.

Progress notes reviewed between 06/05/25 through 08/26/25 noted multiple short-term changes of condition in the following areas:

* Non-injury falls;
* Puking episode;
* Severe diarrhea; and
* Seizure episode.

Although the changes of condition were identified and monitoring was initiated, there was no documented evidence of progress noted to resolution.

Resident 1 was observed throughout the survey to ambulate independently throughout the unit and received feeding cueing/prompting from staff.

Changes of condition with subsequent monitoring through resolution was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN) on 08/28/25 at 3:12 pm. No additional information was provided.

OAR 411-054-0040 (1-2) Change of Condition and Monitoring

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe, sanitary, and comfortable environment related to incontinence care for 2 of 2 sampled residents (#s 1 and 2) whose care was observed. Findings include but are not limited to:

During the survey, bladder and bowel incontinence care was observed being provided to Residents 1 and 2. During both observations, staff were observed not to change gloves after providing perineal care and before touching clean briefs, clothing, and furniture.

The need to ensure staff consistently used universal precautions was discussed with Staff 1 (ED), Staff 2 (MC Wellness Manager/LPN), Staff 13 (Regional RN), and Witness 1 (Nurse Consultant) on 08/28/25. They acknowledged the findings.

OAR 411-054-0050(1-5) Infection Prevention & Control

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure residents were allowed privacy in their own units, related to propping residents’ doors open. Findings include, but are not limited to:

During the survey, multiple doors to resident apartments throughout the memory care community were noted to be propped open with door stoppers, including Residents’ 1 and 2.

In an interview on 08/28/25, Staff 2 (MC Wellness Manager/LPN) reported that doors were propped open for safety measures specific to falls that residents had experienced. She acknowledged that Residents 1 and 2 were unable to consent to this and that propping the doors open had not been discussed with the residents’ powers of attorney.

On 08/28/25, the need to ensure residents were allowed privacy in their own units was discussed with Staff 1 (ED), Staff 2, Staff 13 (Regional RN), and Witness 1 (Nurse Consultant). They acknowledged the findings.

OAR411-004-0020(2)(d) Individual Privacy: Own Unit

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(d) Each individual has privacy in his or her own unit.

This Rule is not met as evidenced by:

Based on interview and record review it was determined the facility failed to ensure Individually Based Limitations (IBLs) were completed when the need to restrict a residents’ rights arose. Findings include, but are not limited to:

Refer to H1517.

OAR411-004-0040(1) Limitations: Threats To Health And Safety

(1) When conditions under OAR 411-004-0020(2)(d) to (2)(j) may not be met due to threats to the health and safety of an individual or others, provider owned, controlled, or operated residential settings must apply individually-based limitations as described in this rule.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure each resident was evaluated for activities, addressing all required elements, and failed to develop an individualized activity plan based on their activity evaluation for 2 of 2 sampled residents (#s 1 and 2) whose evaluations and services plans were reviewed. Findings include, but are not limited to:

The most recent evaluations and current service plans were reviewed for Residents 1 and 2. The following was identified:

a. There was no documented evidence an activity evaluation had been completed for both sampled residents that addressed the following:

* Current abilities and skills;
* Emotional and social needs and patterns;

* Physical abilities and limitations; and

* Adaptations necessary for the resident to participate.

b. There was no documented evidence an individualized plan was developed for both sampled residents.

The need to ensure activity evaluations were completed and individualized activity plans were developed was discussed with Staff 1 (ED) and Staff 2 (MC Wellness Manager/LPN), on 08/28/25. The findings were acknowledged.

OAR 411-057-0160(2d) Activities

(d) Meaningful activities that promote or help sustain the physical and emotional well-being of residents. The activities must be person centered and available during residents ' waking hours. (A) Each resident must be evaluated for activities according to the licensing rules of the facility. In addition, the evaluation must address the following: (i) Past and current interests; (ii) Current abilities and skills; (iii) Emotional and social needs and patterns; (iv) Physical abilities and limitations; (v) Adaptations necessary for the resident to participate; and (vi) Identification of activities for behavioral interventions. (B) An individualized activity plan must be developed for each resident based on their activity evaluation. The plan must reflect the resident ' s activity preferences and needs. (C) A selection of daily structured and non-structured activities must be provided and included on the resident ' s activity service or care plan as appropriate. Daily activity options based on resident evaluation may include but are not limited to: (i) Occupation or chore related tasks; (ii) Scheduled and planned events (e.g. entertainment, outings); (iii) Spontaneous activities for enjoyment or those that may help diffuse a behavior; (iv) One to one activities that encourage positive relationships between residents and staff (e.g. life story, reminiscing, music); (v) Spiritual, creative, and intellectual activities; (vi) Sensory stimulation activities; (vii) Physical activities that enhance or maintain a resident ' s ability to ambulate or move; and (viii) Outdoor activities.

This Rule is not met as evidenced by:

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 main facility kitchen and memory care kitchenette occurred on 04/16/25 from 10:45 am thru 1:30 pm revealed the following deficient practices.

a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Pipes, drain, walls and flooring behind/underneath of the dish machine.
* Kitchen drains.
* Flooring in corners, edges, under and between equipment.
* Industrial mixer.
* Exterior of soup kettle.
* Walk in cooler floors under racks.
* Walk in freezer floors.
* Walk in cooler stationary racks.
* Tall movable metal rack located in walk in cooler.
* Open shelving under steam line.
* Black utility carts.
* Insulated food transportation carts.
* Light fixtures
* Sprinkler heads.
* Cabinet under sink by beverage service station.
* Flooring between steam line and ovens.
* Stove top and grill top.
* Interior of oven in MCC unit
* Interior of reach in refrigerator on unit.
* Interior of cabinets and drawers in kitchenette.

b. The following areas needed repair:

* Large gap/hole in wall where gas line inters/exits wall next/near large industrial mixer
* Reach in cooler with broken/cracked door seal.
* Multiple areas in ceiling where paint/ceiling pealed/chipped or damaged.
* Two small holes in ceiling
* Wall in dry storage with damage behind racks
* Right oven damaged and didn’t work
* Steamer not operational.
* Sections of tile flooring missing grout
* Section of shelving in janitor closet area with porous wood.
* Oven door in kitchenette was damaged and not closing smoothly/currently.

c. Both sanitizer buckets found with zero parts per million of sanitizing agent. Staff was not sure when the bucket was last made. Both containers of strips were noted to be expired as of Jan 1 2019.

d. Staff 2 (Dining Services Manager) was observed to serve cooked to order grilled hamburgers without checking that the temperature of the food product was safe or palatable.

e. Facility did not have a thin prob diameter thermometer probe available for checking temperatures of thin foods.

f. Multiple food contact surfaces of single use plates, etc were noted stored open to potential contamination.

g. Staff 1 was noted to not change gloves after handling potential contaminated items before touching ready to eat food products.

h. Dish washing racks were observed stored on the floor.

i. Multiple cutting boards were observed damaged/stained or heavily scored and in need of replacement.

j. The dining room was noted to have silverware for the Noon meal set on tables at 10:45am and were not covered or inverted as required.

k. Multiple items were found in reach in refrigerator that were not dated/labeled as required. Items were observed in freezer uncovered.

l. Care staff were observed to serving residents food without aprons as required for protective barrier between care giving tasks and meal service tasks.

On 04/16/25 at 1:15 pm, staff 1 (Executive director) was interviewed and acknowledged the above areas in need of correction.

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).

This Rule is not met as evidenced by:
Based on observation, interview and record review, it was determined the facility failed to maintain the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:



Observation of the main facility kitchen occurred on 6/17/25 from 11:08 am through 3:00 pm revealed the following:



a. An accumulation of food spills, splatters, loose food and trash debris, dirt, dust, black matter, and grease was visible on or underneath the following:

* Pipes, drain, walls and flooring above the sink and behind/underneath of the dishwashing area and dish machine;
* Flooring in corners, edges, under and between equipment;
* Industrial mixer;
* Walk-in cooler floors under racks;

* Walk-in cooler stationary racks;
* Tall movable metal rack located in walk in cooler;

* Walk in freezer floors;

* Insulated food transportation carts;
* Cabinet under sink by beverage service station;

* Flooring between steam line and ovens;

* Stove top and grill top; and

* Inside of steamer;

* In the memory care kitchenette, the interior of the oven; and

* In the memory care kitchenette, the interior of cabinets and drawers.


b. The following areas needed repair:


* Active leak under the sink in the dishwashing area;
* Large gap/hole in wall where gas line enters/exits wall next/near large industrial mixer;
* Walk-in cooler with broken door handle and door not sealing properly;
* Left side of oven not heating food evenly;
* Steamer not operational;
* Section of shelving in janitor closet area with porous wood; and

* In the memory care kitchenette, the oven door was damaged and not closing smoothly.



c. Multiple items in the walk-in freezer were open and uncovered.



d. Multiple items in the walk-in cooler were not dated/labeled as required.



e. Drawers near the fridge in the memory care kitchenette stored unsanitary items including previously used hairbrushes.



f. In the memory care kitchenette, multiple items in the reach-in refrigerator were not dated/labeled as required.



g. In the memory care kitchenette, multiple items in the reach-in freezer were uncovered and not dated/labeled as required.



The need to ensure the facility maintained the kitchen in good repair and in a sanitary manner in accordance with Food Sanitation Rules, OAR 333-150-000, was reviewed with Staff 1 (ED) and Staff 3 (ED in training) on 06/17/25 at 3:15 pm. They acknowledged the findings.

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).

This Rule is not met as evidenced by:

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

Refer to C 240.

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.

This Rule is not met as evidenced by:

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

Refer to C240.

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.

This Rule is not met as evidenced by:
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 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.

This Rule is not met as evidenced by:

The findings of the on-site investigation, conducted 11/02/23 through 11/02/23, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

The findings of the on-site investigation, conducted xx/xx/xx, are documented in this report. The investigation was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities. Abbreviations possibly used in this document:ADL: activities of daily livingCBG: capillary blood glucose or blood sugar CG: caregiverCS: Compliance Specialistcm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMT: Medication TechMAR: Medication Administration RecordMCC: Memory Care CommunityOT: Occupational TherapistPT: Physical TherapistPRN: as neededRCC: Resident Care CoordinatorRN: Registered Nurse

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 01/11/2023. 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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

The findings of the re-licensure survey, conducted 10/10/22 through 10/13/22, 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, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the first re-visit to the re-licensure survey of 10/13/22, conducted from 08/14/23 through 08/16/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities.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 livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day

The findings of the second revisit to the re-licensure survey of 10/13/22, conducted 11/08/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.

Based on observation, interview and record review, it was determined the licensee failed to provide effective oversight to ensure the quality of care and services that were rendered in the facility. Findings include, but are not limited to:During the re-licensure survey, conducted 10/10/22 through 10/13/22, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number and severity of citations.Refer to deficiencies in the report.

Based on observation and interview, it was determined the facility failed to ensure infection control measures were consistently implemented related to incontinent care and that reasonable precautions were taken for resident safety related to potential elopement risk. Findings include, but are not limited to:1. On 10/10/22 at 3:16 pm, the surveyor observed two caregivers provide incontinent care to Resident 3. During the process, Staff 13 (CG) removed the resident's soiled incontinent brief, which had both feces and urine, and threw it over the resident's wheelchair towards the garbage can approximately four feet away. The brief was turned inside out after removal and landed soiled side down on the floor. Staff 9 (CG) picked up the brief and placed it in the garbage a few minutes later.Staff 9 failed to change gloves after picking up the soiled incontinent brief and wiping the resident's bottom and perineal area. Staff 9 touched the resident's new brief, clothing and wheelchair while wearing the same gloves used to provide incontinent care. The surveyor asked Staff 9 to stop and change her gloves before continuing to assist the resident to the dining room. Staff 9 and 13 both indicated they were unaware of the need to change gloves after providing incontinent care and completing other tasks with a resident. In an additional interview conducted at 3:55 pm, Staff 13 indicated the floor was cleaned and the garbage emptied. Observation of the restroom used showed all incontinent items were removed. The need to ensure staff consistently used proper infection control and universal precautions when incontinent care was provided was discussed with Staff 1 (Interim Administrator) and Staff 2 (MC Program Director) on 10/12/22. They acknowledged appropriate infection control practices were not being followed.2. Observations of the windows in resident apartments of the memory care on 10/10/22, showed nine rooms with windows that opened fully to unsecured outdoor areas. A few of the apartments had wood dowels sitting in the window track, while others had nothing in the window at all. The dowels were easily picked up and moved to allow windows to open fully. An additional apartment had two sets of windows. One window opened fully and the second window had a metal bracket screwed into the window track.In an interview on 10/10/22, Staff 7 (Maintenance Director) was shown the unsecured windows and the metal bracket. Staff 7 indicated he utilized the dowels to keep the windows from opening fully from the outside. He understood the dowels did not prevent residents from opening the windows fully. Staff 7 indicated he would purchase thumb screws to secure the windows.Additional observations of the windows showed thumb screws in place which would prevent resident's from easily removing and fully opening windows. However, the thumb screws would allow staff to remove quickly in case of emergency. All windows were secured with the thumb screws approximately one hour after Staff 7 was shown the issue. The need to ensure windows in the memory care did not fully open to unsecured areas and create potential elopement risks was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Director) on 10/11/22 and 10/12/22. They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure reasonable precautions were taken for resident safety related to potential elopement risks. This is a repeat citation. Findings include, but are not limited to:Observations of windows in resident apartments of the memory care on 08/14/23, showed nine rooms with windows that opened fully to unsecured outdoor areas. Seven of the nine rooms were observed with window frame thumb screws either not attached, substantially loose, or the screw of the mechanism was missing. This allowed the seven windows to be fully opened to the unsecured outdoor areas of the building.In an interview on 08/14/23, Staff 24 (Memory Care RCC) was shown the unsecured windows and the thumb screw mechanisms. She acknowledged the thumb screws failed to prevent residents from opening the windows fully, creating a potential elopement risk.On 08/14/23, the need to ensure windows in the memory care did not fully open to unsecured areas and create potential elopement risks was discussed with Staff 23 (Executive Director) and Staff 24. They acknowledged the findings and reattached and tightened the locking mechanisms the same day.

Based on interview and record review, it was determined the facility failed to ensure injuries of unknown cause, falls and resident to resident altercations were promptly and thoroughly investigated to rule out abuse and neglect and reported to the local SPD office as required for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose incidents were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia. The resident's care plan dated 09/16/22 and interviews with care staff between 10/10/22 and 10/13/22 indicated the resident was dependent for ADL care. The resident could transfer and walk on his/her own and had a history of frequent resident to resident altercations and refusal of care. The resident was unable to safely direct his/her own care. Review of incident investigations, physician communications and progress notes from 07/02/22 through 10/09/22 showed the following: * A progress note dated 07/12/22 indicated the resident was on alert for a resident to resident altercation on 07/11/22. No further information was noted about the incident. No investigation was located regarding the incident and no report was made to the local SPD.* A fax to the physician on 09/15/22 indicated there was a resident to resident altercation and Resident 1 had struck another resident. No investigation was located and the incident was not reported to the local SPD. * Progress notes dated 09/26/22 indicated the resident had experienced two falls on that day. No injuries were noted. There were no investigations of the falls to reasonably rule out abuse nor reported to SPD.The facility was asked to report the resident to resident altercations to the local SPD office and confirmation of the reports was received prior to exit.The need to ensure resident incidents, were promptly and thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia. The resident's care plan dated 09/26/22 and interviews with care staff between 10/10/22 and 10/13/22 indicated the resident was dependent for ADL care. The resident could transfer and walk on his/her own and had a history of falls and resident to resident altercations. The resident was unable to direct his/her own care. Review of incident investigations, physician communications and progress notes from 07/02/22 through 10/09/22 showed the following: * A progress note dated 07/11/22 indicated the resident had a resident to resident altercation and was hit in the arm by the other resident. There were no other details about the incident. No investigation was completed and no report was made to the local SPD office. * A progress noted dated 07/12/22 indicated the resident experienced a non-injury fall. No investigation was completed to reasonably rule out abuse or neglect.* An incident report dated 07/20/22 indicated the resident had two golf ball size bruises to the right hand and right forearm. The investigation was not thorough and did not rule out abuse or neglect. The injuries of unknown cause were not reported to the local SPD office. * A progress note dated 09/19/22 indicated a bruise was found to the top of the right hand. No investigation was completed for the injury of unknown cause to reasonably rule out abuse and was not reported to the local SPD office.* A progress note dated 10/02/22 indicated a bruise was found to the resident's left shin. No investigation was completed for the injury of unknown cause.The facility was asked to report the resident to resident altercations and injuries of unknown cause to the local SPD office and confirmation of the reports was received prior to exit.The need to ensure resident incidents, were promptly and thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in October 2015 with diagnoses including dementia. The resident's care plan dated 09/21/22 and interviews with care staff between 10/10/22 and 10/13/22 indicated the resident was dependent for all ADL care. The resident was wheelchair bound and required two staff assistance for transfers. Review of incident investigations 05/01/22 through 10/09/22 and physician communications and progress notes from 07/02/22 through 10/09/22 showed the following: * An incident report dated 05/01/22 indicated during a brief check, bruising to the left upper, inner thigh was noted. The investigation indicated the resident scratched himself/herself and noted the bruising was "probably R/T (related to) transfers." The investigation lacked information to rule out abuse or neglect and prevent reoccurrence.* An incident report dated 07/27/22 indicated bruising to the left hand was found. The investigation was not thorough to rule out abuse or neglect.* A fax to the physician dated 08/09/22 indicated the resident had two new bruises found during a shower. No investigation was completed for the injury of unknown cause and was not reported to the local SPD office. * An incident report dated 08/18/22 indicated a new bruise was found to the left outer forearm. The report indicated bruise was caused by the resident squeezing his/her own arms too tightly. There were no witnesses to the cause of the bruise and the investigation lacked information to rule out abuse or neglect. * An incident report dated 08/20/22 indicated two "new bruises" were found on the resident's right forearm and hand. Interventions were noted as long sleeves and "remind staff to use gentle hands." The investigation lacked information to rule out abuse or neglect.* An incident report dated 09/15/22 indicated the resident sustained a 10 cm skin tear to the outside of his/her left calf during a transfer. The investigation lacked information to rule out abuse or neglect and prevent reoccurrence.*A fax to the physician dated 09/15/22 indicated staff observed another resident hit Resident 3 in the arm. No investigation was located regarding the resident to resident altercation.* A progress note dated 09/22/22 indicated the resident had a bruise to the right thigh. No investigation was completed regarding the injury of unknown cause.The facility was asked to report the incidents to the local SPD office and confirmation of the reports was received prior to exit.The need to ensure resident incidents, were promptly and thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. The staff acknowledged the findings. 4. Resident 4 was admitted to the facility in October 2020 with diagnoses including dementia. The resident's care plan dated 09/19/22 and interviews with care staff between 10/10/22 and 10/13/22 indicated the resident was dependent for ADL care. The resident could transfer and walk on his/her own and had a history of frequent resident to resident altercations and refusal of care. The resident was unable to safely direct his/her own care. Review of incident investigations, physician communications and progress notes from 07/05/22 through 10/10/22 showed the following: * An incident report dated 07/29/22, indicated during care a bruise was found on the resident's right hip and right elbow. The investigation lacked information to rule out abuse or neglect and prevent reoccurrence.* A progress noted dated 08/18/22, indicated the resident was put on alert for a softball size bruise to the left buttocks found on 08/17/22. No investigation was completed for the injury of unknown cause. The facility was asked to report the incidents to the local SPD office and confirmation of the reports was received prior to exit.The need to ensure resident incidents, were promptly and thoroughly investigated to rule out abuse and neglect was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. The staff acknowledged the findings.

2. Observations of the MCC kitchenette from 10/10/22 through 10/12/22 showed the following: * Debris, spills and stains were noted inside numerous drawers and cupboards. Cupboard shelves had scrapped and peeling surfaces; * Dust, debris, dead insects and black accumulation was noted in the windowsill behind the sink;* Spills and debris were noted on the refrigerator shelves and surfaces. A shelf on the door was cracked and had flaky, yellow and white substance on the surface;* Debris and dark accumulation was noted along the edges of the floor underneath the cupboards;* Debris and brown accumulation was on the side of the stove;* Spills and debris were noted to the inside and outside of the oven;* Meals delivered to the MCC unit had uncovered desserts on an open shelf of the cart for multiple meals;* Numerous items served to resident plates with spatulas or spoons without measurement to ensure adequate portions were provided. Servings on resident plates were of inconsistent sizes with some residents receiving very small partial portions and others received large portions;* Staff plating foods from inside the kitchenette and delivering plates to residents, did not have aprons in place over clothing; and* Staff inconsistently utilized proper hand hygiene between clean and dirty tasks, glove changes and meal delivery/plating.The need to ensure the kitchenette was kept clean and in good repair, that staff utilized proper hand hygiene and apron use was discussed with Staff 1 (Interim Administrator) on 10/11/22 and 10/12/22. He acknowledged the findings.
Based on observation and interview, it was determined the facility failed to ensure the kitchen was maintained in a clean and sanitary manner and that food was prepared and served in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. Observations of the facility kitchens, food storage areas, food preparation, and food service on 10/10/22 through 10/12/33 indicated the following: The facility's main kitchen was toured on 10/10/22 and showed the following: * Dried food debris on the meat slicer and the stand mixer whisk;* Gray, greasy film on microwave, microwave stand, and ware washer, including temperature gauges, rendering them unreadable; * Food debris on floor, underneath racks in dry storage room, and a peanut butter cookie was on top of a storage bin;* Gray matter on blue cup racks;* Food debris on side of grill;* Dark matter and dust on grill hood;* Multiple food packages were open in the dry storage room, and the lid was off the oatmeal storage bin;* Gallon of honey mustard dressing in the walk-in cooler was expired;* Multiple items in the walk-in cooler were not dated;* Paper signs were throughout the kitchen, creating uncleanable surfaces;* Garbage cans throughout kitchen did not have lids;* Back door had multiple areas of chipped and worn paint, creating an uncleanable surface.These findings were reviewed with Staff 1 (Interim Administrator) on 10/13/22. He acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs, provided clear direction to staff regarding care and services and were followed by staff for 2 of 4 sampled residents (#s 2 and 3) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan dated 09/26/22, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Ability to manage finances;* Falls and safety interventions;* Incontinent care, bowel and bladder management;* Hygiene and skin injuries;* Night time checks and resident sleep routines;* Transfers and ambulation; and* Verbal and physical aggression.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings.2. Resident 3 was admitted to the facility in October 2015 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the service plan dated 09/21/22, showed the service plan was not reflective of the resident's current care needs, was not consistently followed by staff and/or did not provide clear direction to staff in the following areas: * Falls, low bed, fall mat;* Transfers, two staff assistance and gait belt use;* Limited ability to bare weight, weakness and knee buckling;* Incontinent care and toileting needs;* Extended period needed to consume meals;* Foot cradle use and foam booties;* Elevating legs, foot swelling and edema;* Foam booties; and* Anxiousness with care and not rushing the resident. The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings.

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 documentation a Service Planning Team reviewed and participated in the development of the service plans.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure residents who had short-term changes of condition were evaluated, resident-specific instructions or interventions were developed and reviewed for effectiveness and the condition was monitored to resolution at least weekly for 2 of 4 sampled residents (#s 1 and 2) who experienced changes of condition. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia with behaviors. Interviews with staff and review of the resident's 09/16/22 service plan, 07/02/22 through 10/09/22 progress notes, incident investigations and physician communications were completed.The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* Resident to resident altercations;* Blood in the stool;* Edema; and* New medications and medication changes.The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings.2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia.Observations of the resident, interviews with staff and review of the resident's 09/26/22 service plan, 07/02/22 through 10/09/22 progress notes, incident investigations and physician communications were completed.The resident experienced multiple short-term changes without documented monitoring at least weekly until resolution, interventions were not reviewed for effectiveness and/or lacked resident-specific directions to staff in the following areas:* New medications and medication changes;* Resident to resident altercations; and* Multiple bruised areas of the body. The need to ensure short-term changes of condition had documentation to reflect monitoring to resolution at least weekly and provided clear, resident-specific directions to staff was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure an RN assessment was completed for 1 of 1 sampled resident (#3) who experienced significant changes of condition related to weight loss. Resident 3 experienced severe weight loss. Findings include, but are not limited to:Resident 3 was admitted to the facility in October 2015 with diagnoses including dementia. The resident was previously admitted to hospice on 05/26/22 related to weakness and advancing dementia. No weights prior to July 2022 could be located. Weight records, dated 07/02/22 through 10/04/22 and progress notes dated 07/02/22 through 10/09/22, indicated the resident experienced a 7.4 pound weight loss from July 2022 to August 2022. This constituted a 5.22% severe weight loss in one month. The resident continued to experience weight loss through 10/04/22. The resident experienced an 11.4 pound weight loss from 07/02/22 to 10/04/22, which constituted an 8.05% in three months. A current weight of 131.2 was obtained immediately after lunch on 10/13/22, the resident's previous weight was 130.2.Progress notes and physician communications dated 07/02/22 through 10/10/22 indicated the resident had increased weakness and difficulty assisting with transfers. The resident's intake varied and s/he received a mechanically soft diet. The resident required full assistance from staff for his/her ADLs but could feed himself/herself once meal items were delivered. The resident had multiple medication changes, bruising to multiple locations on his/her body and toe swelling.Multiple observations of the resident between 10/10/22 and 10/13/22 showed the resident was independent with his/her meal once it was delivered. The resident ate in the dining room, received cut up foods and 2-3 cups of fluid, usually a juice, coffee and/or water. The resident ate 50-100% of the meals observed and also accepted snacks/drinks when offered during activities or snack/hydration pass. The resident did require intermittent cueing to continue with his/her meal and fluids. The resident's portion sizes at each meal varied widely from very small portions of approximately ¼ cup to larger portions closer to 1 cup. The resident was not offered additional helpings of any of the meal items. The resident spent 30-60 minutes at the table eating which varied by the time of day.In interviews on 10/10/22, Staff 10 and 17 (CGs) indicated the resident's intake was fair to good. The staff indicated the resident needed a lot of time to get through the meal and ate very slowly. The resident required reminders to continue to eat and drink but could do on his/her own. In interviews on 10/12/22, Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) confirmed there was no additional information regarding an RN assessment from the previous nurse. Staff 2 indicated the resident enjoyed his/her food and loved cookies and coffee. She was unaware of any health shakes or supplements currently in place. Staff 2 was absent from the facility for several months around the time of the resident's weight loss. The facility failed to ensure an RN assessment was completed for the weight loss documented in August 2022 which documented findings, resident status and interventions made as a result of the assessment. The resident continued to experience weight loss.The need to ensure an RN assessment was completed which documented findings, resident status and interventions made as a result of the assessment was discussed with Staff 1 and Staff 2. The staff acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure it consistently complied with masking requirements as prescribed in OAR 333-019-1011. Findings include, but are not limited to:Per Oregon Administrative Rule 333-019-1011(6), (8) and (10), persons employed in an assisted living or residential care facility are required to wear a face mask while they are in the facility except when the employee is alone in a closed room.Observations of staff during the survey revealed multiple instances where staff failed to wear their face mask properly, exposing their nose, or nose and mouth.The need to ensure staff consistently wore a face mask was reviewed with Staff 1 (Interim Administrator) and Staff 2 (MC Program Manager on 10/11/22 and 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 3 of 3 sampled residents (#s 1, 2 and 3) whose MARs and Controlled Substance Disposition logs were reviewed. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 09/26/22 included the following order:* Lorazepam 1.0 mg tab, take one tablet by mouth every four hours PRN for anxiety or restlessness.The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/22 through 10/10/22 showed the following:* On 09/22/22, 09/23/22, 09/24/22 and 09/25/22 PRN doses of Lorazepam were administered but not recorded on the MAR.Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22 and 10/13/22. The staff acknowledged the findings. 2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 09/26/22 included the following orders:* Lorazepam 1.0 mg, take one tablet by mouth PRN every four hours PRN for anxiety or shortness of breath.The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/22 through 10/10/22 showed the following:* On 09/21/22, 09/22/22 at 2:30 pm and 8:00 pm, and 10/04/22 PRN doses of Lorazepam were recorded on the disposition log but were not reflected on the MARs; and* On 09/06/22 a PRN dose of Lorazepam was recorded on the MAR but was not signed out on the disposition log.Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22 and 10/13/22. The staff acknowledged the findings. 3. Resident 3 was admitted to the facility in October 2015 with diagnoses including dementia. Observations of the resident, interviews with staff and record review were completed. The resident's signed physician orders dated 08/19/22 included the following order:* Oxycodone/APAP 5-325 mg, take one tablet by mouth PRN every six hours for pain.The resident's Controlled Substance Disposition logs and MARS, reviewed from 09/01/22 through 10/10/22 showed the following:* On 09/1/22, 09/2/22, 09/08/22, 09/09/22, 09/12/22, 09/15/22, 09/16/22, 09/22/22, 09/23/22, 09/26/22, 10/03/22, 10/07/22 and 10/09/22, PRN doses of Oxycodone were signed out on the disposition log but were not recorded on the MAR. The doses were signed out in the afternoon between 2:15 and 2:30 pm. * On 09/30/22 at 8:40 pm, 10/06/22 at 8:50 pm and 10/09/22 at 8:10 pm a PRN dose of Oxycodone was signed out on the disposition log but was not recorded on the MAR.* On 09/04/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:30 pm but was not recorded as administered until 3:53 pm on the MAR.* On 09/05/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:35 pm but was not recorded as administered until 4:25 pm on the MAR.* On 09/18/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:30 pm but was not recorded as administered until 4:25 pm on the MAR.* On 09/19/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:30 pm but was not recorded as administered until 4:17 pm on the MAR.* On 09/25/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:40 pm but was not recorded as administered until 4:39 pm on the MAR.* On 10/02/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:30 pm but was not recorded as administered until 4:12 pm on the MAR.* On 10/06/22 a PRN dose of Oxycodone was signed out on the disposition log at 2:40 pm but was not recorded as administered until 4:22 pm on the MAR. Comparison of the medication bubble packs to the disposition logs, showed the amount of medication left was reflected accurately on the log. In interview on 10/12/22, Staff 2 (MCC Program Manager) indicated she believed the holes in documentation were related to their Internet connection and the medications were administered. She was unable to provide any additional documentation on the dates in question. The need to ensure narcotic disposition logs accurately reflected the medications administered was discussed with Staff 1 (Interim Administrator) and Staff 2 on 10/12/22 and 10/13/22. The staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was maintained for all facility administered medications and orders for 3 of 3 sampled residents (#1, 2 and 3) whose medication records were reviewed. Findings include, but are not limited to: 1. Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia. Review of the resident's 07/02/22 through 10/09/22 progress notes, physician communications, and the 09/01/22 through 10/10/22 MARs showed the following:* Hycosamine sulfate 0.125 mg give one tablet PRN for excess secretions. There was no direction to staff on what to watch for prior to administration;* Multiple PRN administrations of Lorazepam and Haloperidol lacked documentation for the specific reason the medication was administered; and* Multiple supplements and prescription medications lacked documented reasons for use.The need to ensure MARs had complete documentation for all orders was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Director) on 10/12/22. They acknowledged the findings. 2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia. Review of the resident's 07/02/22 through 10/09/22 progress notes, physician communications, and the 09/01/22 through 10/10/22 MARs showed the following:* Hycosamine sulfate 0.125 mg give one tablet PRN for excess secretions. There was no direction to staff on what to watch for prior to administration;* Milk of Magnesia, take 30 ml PRN daily for constipation. There was no direction to staff on when to initiate the bowel medication; and* Multiple PRN administrations of Lorazepam and Morphine lacked documentation for the specific reason the medication was administered.The need to ensure MARs had complete documentation for all orders was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Director) on 10/12/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in October 2015 with diagnoses including dementia. Review of the resident's 07/02/22 through 10/09/22 progress notes, physician communications, and the 09/01/22 through 10/10/22 MARs showed the following:* Hycosamine sulfate 0.125 mg give one tablet PRN for excess secretions. There was no direction to staff on what to watch for prior to administration;* Oxycodone and Morphine were both ordered PRN for resident complaints of pain. The MAR contained no directions for staff on which medication to utilize first; and* Two orders for Senna 8.6 mg, take one tablet PRN for constipation were noted on the MAR. One directed use for morning administration and one for bedtime administration. The MAR contained no directions for staff on when to initiate administration of the PRN bowel medication.The need to ensure MARs had complete documentation for all orders was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Director) on 10/12/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure PRN medications used to treat a resident's behavior had written, resident-specific parameters and non-drug interventions for staff to attempt prior to administering a PRN psychoactive medication, for 3 of 3 sampled residents (#s 1, 2 and 3) who were prescribed a PRN medication to address behaviors. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in October 2021 with diagnoses including dementia.Review of the resident's 09/01/22 through 10/10/22 MARs and progress notes and 09/26/22 physician orders showed the following:* Lorazepam 1.0 mg (anti-anxiety medication), one tablet every four hours PRN for anxiety or restlessness. An order change was made on 09/26/22 for Lorazepam 0.5 mg, one tablet every four hours PRN for anxiety or agitation. The 1.0 mg Lorazepam was administered nine times between 09/01/22 and 10/10/22. * Haloperidol concentrate 2 mg/ml, take 0.5 ml every four hours PRN for anxiety or restlessness.The Haloperidol was administered three times between 09/01/22 and 10/10/22.The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety, restlessness or agitation. Additionally, there was no documentation of what non-drug interventions were attempted prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings. 2. Resident 2 was admitted to the facility in July 2019 with diagnoses including dementia.Review of the resident's 09/01/22 through 10/10/22 MARs and progress notes and 09/26/22 physician orders showed the following:* Lorazepam 1.0 mg (anti-anxiety medication), one tablet every four hours PRN for anxiety or shortness of breath. The Lorazepam was administered nine times between 09/01/22 and 10/10/22. * Haloperidol concentrate 2 mg/ml, take 0.5 ml every four hours PRN for anxiety or restlessness.The Haloperidol was not administered between 09/01/22 and 10/10/22.The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or restlessness. Additionally, there was limited direction for staff on what non-drug interventions should be attempted prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Manager) on 10/12/22. They acknowledged the findings. 3. Resident 3 was admitted to the facility in July 2019 with diagnoses including dementia.Review of the resident's 09/01/22 through 10/10/22 MARs and progress notes and 09/26/22 physician orders showed the following:* Lorazepam 0.5 mg (anti-anxiety medication), one tablet every four hours PRN for anxiety or restlessness. The Lorazepam was not administered between 09/01/22 and 10/10/22. The MARs did not contain resident-specific parameters for staff describing how the resident expressed anxiety or restlessness. Additionally, there was only one non-drug intervention documented for staff to attempt prior to administration of the medication. The need to ensure resident-specific information on how the resident expressed anxiety/agitation and that non-drug interventions were attempted and documented prior to administration of the medication was discussed with Staff 1 (Interim Administrator) and Staff 2 (MC Program Manager) on 10/12/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to have sufficient number of caregivers to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:During the entrance conference on 10/10/22 the following was identified: * The facility had 14 residents;* Three residents needed two-person assistance with transfers and/or care, for all or part of their care;* Two residents were identified to have frequent resident to resident altercations;* Six residents were on hospice or palliative care; * Four residents were identified as heavy care and needed full assistance with ADLs related to physical abilities, cognitive deficits and/or behaviors; and* Multiple residents were identified with behavioral issues needing constant cueing, monitoring and/or redirection. The staffing plan for October 2022 provided by the facility was as follows: * Day shift 1 MT and 2 CG's;* Evening shift 1 MT and 2 CG's; and * Night shift 1 MT and 1 CG. Review of the facilities payroll information for 08/15/22 to 08/31/22, 09/09/22 to 09/20/22 and 10/01/22 to 10/10/22 showed the following:* 12 occasions when day shift was short a CG and/or a MT, this left two staff in the unit;* 26 occasions when evening shift was short a CG and/or a MT, this left two staff in the unit; and* 12 occasions when night shift was short a CG or a MT, this left only one staff in the unit.Observations of the memory care unit on 10/11/22 between 4:45 am and 5:45 am showed one CG was in the unit. Four residents were awake and in the TV area, some in pajamas and others dressed for the day. One resident was asleep in a chair in the TV area. Staff 17 (CG) was observed to assist other residents in their apartments as well as using the restroom herself, with no coverage on the floor. At approximately 5:28 am, Staff 17 left the memory care unit to locate coffee for the residents, she returned within five minutes. The only non-resident in the memory care unit was the surveyor. Additional observations of the memory care unit from 10/10/22 to 10/13/22, showed staff provided care for the residents, plating and serving of meals and clean up. Staff provided frequent observation and redirection of residents who were wandering around the unit, invading the physical space of other residents and attempting to enter rooms of those easily upset by the intrusion. In an interview on 10/11/22 at 4:40 am, Staff 13 (MT) indicated he was covering medications for the assisted living facility and the memory care. He indicated there was one caregiver in the memory care and one caregiver trainee in the assisted living with him. In an interview on 10/11/22 at 5:35 am, Staff 17 indicated she was gone only briefly and did not think about the unit having no staff. She understood the residents needed to be supervised. Staff 17 worked swing shift on 10/10/22 and stayed over to cover night shift and heard there was a call in for the MT who was supposed to be working.Interviews with multiple memory care staff, between 10/10/22 and 10/12/22, indicated there were several occasions when shifts were short staffed, night shift seemed to be the most difficult to get coverage and continued to be a problem. The staff indicated their duties included resident care, laundry, clean up of the dining room, plating of food, serving of food and removal of used dishes for transport to the dining room. The staff indicated there were two residents who had frequent resident to resident altercations with others and could be combative with ADL care. The need to ensure resident supervision was maintained throughout each shift and to ensure enough staff were available to meet the scheduled and unscheduled needs of the residents was discussed with Staff 1 (Interim Administrator) and Staff 2 (MCC Program Director) on 10/11/22, 10/12/22 and 10/13/22. The staff acknowledged the staffing concerns and indicated they were working to hire additional staff and utilizing agency as they could. The staff acknowledged the residents of the memory care unit should not be left unsupervised.

Based on interview and record review, it was determined 2 of 3 sampled, newly hired direct care staff (#s 10 and 20) failed to complete First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:A review of the facility's training records on 10/12/22 and again on 10/13/22 revealed: Staff 10 (CG) hired on 08/16/22 and Staff 20 (CG) hired on 03/07/22 did not have documentation of first aid and abdominal thrust training completion within the required 30 days of hire.The need to ensure First Aid and abdominal thrust training was completed within 30 days of hire was discussed with Staff 1 (Interim Administrator) and Staff 3 (Business Office Manager) on 10/13/22. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire and life safety training was documented as completed on alternating months for memory care staff. Findings include, but are not limited to:Fire drill records were reviewed from April 2022 to September 2022. The following deficiencies were identified:* There was no documented evidence the facility was conducting fire drills every other month on alternating shifts for the memory care community; and * There was no documented evidence that fire life safety training was conducted on alternating months from the fire drills. In interview on 10/11/22, Staff 7 (Maintenance Director) indicated he regularly discussed fire drill procedures with the memory care staff. Staff 7 stated he did not have any documentation of drills completed in the memory care unit.The requirements regarding fire drills and fire and life safety instruction for staff were reviewed with Staff 1 (Interim Administrator) and Staff 7 on 10/11/22. The staff acknowledged the findings.

Based on interview and observation, it was determined the facility failed to ensure their re-licensure survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C160 and C510.

Based on observation and interview, it was determined the facility failed to ensure courtyard surfaces were maintained in good repair, fencing was adequate to prevent potential injury and that chemicals were secured. Findings include, but are not limited to:a. Observations of the secure outdoor area on 10/10/22 showed the following:* Multiple drop offs greater than two inches along pathway edges; * A gap of approximately five inches high was noted at the bottom of the fence, in the back corner of the secured courtyard. The gap ran along one section of the fence that was approximately five feet wide; and * Chipped concrete and a raised section of concrete which created an uneven surface.b. Spray bottles with liquid, were labeled "Sani-quat" and disinfectant written on blue tape. The bottles were located in an unlocked cupboard under the kitchen sink. A gate across the kitchen entry was inconsistently secured when staff were out of the kitchenette and dining area. The need to ensure pathways were free of safety hazards and cleaning chemicals were consistently secured was discussed with Staff 1 (Interim Administrator) on 10/10/22. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure chemicals were secured. This is a repeat citation. Findings include, but are not limited to:Observations on 08/14/23 of the memory care kitchenette revealed the following:Disinfectant bottles and other cleaning chemicals were located in a cabinet under the kitchenette sink. This cabinet was observed unlocked on multiple occasions without staff in the kitchenette. The gate across the kitchenette entry was inconsistently secured on multiple occasions without staff nearby. On 08/14/23, the need to ensure cleaning chemicals were consistently secured was discussed with Staff 23 (Executive Director). She acknowledged the findings.

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 facility on 10/10/22 and 10/11/22 showed the following areas were in need of cleaning or repair:* Numerous large dark stains were noted on the carpet in the common areas, at the entrance to the unit and in rooms 140, 150 and 151;* Numerous dining room chairs had black, white, orange and/or brown spills down the armrests and both sides of the seat backs; * Furniture in the TV room/common area had large dark black, brown or red stains along seats and arms;* Multiple doors had black streaks, scrapes and/or cracked plastic kick plates;* Dark accumulation was noted along baseboards in the dining room and common area bathroom as well as a large hole in the wall behind the toilet in the bathroom;* Spills and black streaks noted down multiple walls in the unit;* Three dining room tables had large pieces of missing laminate along the edges;* The spa room had missing and discolored caulking around the toilet, cracked and discolored caulking at the edge of the shower and dark accumulation along the edges of the rubber baseboards;* Multiple walls, corners and doors had chips, scrapes or dings;* Room 135's bathroom had cracked and discolored caulking around the toilet and edges of the shower;* Transition rubber between TV room carpet and laminate in the dining room was chipped, dented and separating from carpet edges;* Spills and debris were noted on the handrail nearest the kitchenette; and* The floor transition for room 132 was pulling up.The areas in need of cleaning and/or repair were shown to and discussed with Staff 1 (Interim Administrator) on 10/11/22. He acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure all exit doors were equipped with an alarming device or other acceptable system to provide security and to alert staff when residents exited the building. Findings include, but are not limited to:Observations on 10/10/22 through 10/12/22 showed exit doors to the resident courtyard did not have an operational alarm or other acceptable system to alert staff when residents exited the building. The need to ensure exit doors were equipped with a functional alarming device or other acceptable system was discussed with Staff 1 (Interim Administrator) and Staff 7 (Maintenance Director) on 10/11/22. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to provide effective administrative oversight over the operation of the Memory Care Community. Findings include, but are not limited to:The licensee is responsible for the operation of the MCC and the provision of person-directed care that promotes each resident's dignity, independence and comfort. This includes the supervision and overall conduct of the staff.During the re-licensure survey, conducted 10/10/22 through 10/13/22, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the number and severity of citations. Refer to deficiencies in the report.

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 C150, C160, C231, C240, C262, C295, C360, C372, C420, C510, C513 and C555.
Based on observation, interview, and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C160 and C510.

Based on interview and record review, it was determined the facility failed to ensure 3 of 3 newly hired staff completed all required pre-service training areas prior to beginning work on the floor and demonstrated competency in all required areas within 30 days of hire and 2 of 3 long-term staff completed a total of 16 hours of annual in-service training. Findings include, but are not limited to:Staff training records were reviewed on 10/11/22 and 10/12/22. The following was identified:a. There was no documented evidence Staff 10 (CG), Staff 15 (CG), and Staff 20 (CG), hired 08/16/22, 02/22/22, and 03/07/22, respectively, completed required pre-service training in the following areas:* Resident rights and values of CBC care;* Abuse Reporting requirements;* Infectious Disease Prevention;* Written job description;* Environmental factors that are important to a resident's well-being; and* Use of supportive devices with restraining qualities in memory care communities.b. There was no documented evidence Staff 10 (CG), Staff 15 (CG), and Staff 20 (CG), hired 08/16/22, 02/22/22, and 03/07/22, respectively, demonstrated competency in the following areas within 30 days of hire:* Role of service plans in providing individualized care;* Providing assistance with ADL's;* Changes associated with normal aging;* Identification, documentation, and reporting of changes of condition;* Conditions which require assessment, treatment, observation, and reporting; and* General food safety, serving and sanitation.c. There was no documented evidence Staff 9 (CG) hired 02/01/10 and Staff 14 (CG/MT) hired 08/14/18, completed the required number of hours of annual in-service training, including dementia training in 2021 through 2022. Training records reviewed were 02/2021 - 02/2022 and 08/2021-08/2022, respectively.Staff 3 (Business Office Manager), in an interview on 10/12/22, reported she had no further documentation related to pre-service training, 30 day competency completion or annual training for the staff reviewed. The need to ensure all new hires completed pre-service requirements, demonstrated competency in job duties and long term staff completed the required 16 hours of annual in-service training was discussed with Staff 1 (Interim Administrator) on 10/13/22. He acknowledged the findings.

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 C260, C270, C280, C302, C310 and C330.

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space which allowed residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e). Findings include, but are not limited to:Observations during the survey between 10/10/22 and 10/12/22 showed the doors to the exterior courtyard were locked and did not allow residents to exit and return without staff assistance.In interview on 10/10/22, with multiple caregiving staff and Staff 7 (Maintenance Director) they acknowledged the doors were locked and they thought residents were only allowed outside in the exterior courtyard areas when escorted by staff. Staff 7 was not sure how to unlock the keypad for an extended period. The need to ensure residents have access to the secured outdoor spaces without staff assistance was discussed with Staff 1 (Interim Administrator) on 10/11/22. He acknowledged the findings.