Hawthorne Gardens Memory Care Community

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 change of ownership survey, conducted 06/09/25 through 06/11/25, oversight to ensure adequate resident care and services rendered in the facility was found to be ineffective based on the number of citations.

Refer to deficiencies in report.

OAR 411-054-0025 (1) Facility Administration: Operation

(1) FACILITY OPERATION. (a) The licensee is responsible for the operation of the facility and the quality of services rendered in the facility. (b) The licensee is responsible for the supervision, training, and overall conduct of staff when staff are acting within the scope of their his or her employment duties.(c) The licensee is responsible for ensuring that the facility complies with the tuberculosis screening recommendations in OAR 333-019-0041.(d) The licensee is responsible for obtaining background checks on all subject individuals.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors. Findings include, but are not limited to:

The facility was toured on 06/09/25 at 9:15 am. The following were not posted as required:

* The name of administrator or designee in charge posted by shift; and
* The LGBTQIA2S+ nondiscrimination notice.

The need to ensure required postings were in a routinely accessible and conspicuous location to residents and visitors was discussed with Staff 1 (ED) and Staff 2 (MCC Administrator) on 06/09/25. They acknowledged the findings.

OAR 411-054-0025 (5) Facility Administration: Required Postings

(5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following:
(a) Facility license.
(b) The name of the administrator or designee in charge. The designee in charge must be posted by shift or whenever the administrator is out of the facility.
(c) The current facility staffing plan.
(d) A copy of the most recent re-licensure survey, including all revisits and plans of correction as applicable.
(e) The Ombudsman Notification Poster.
(f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections.
(g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.
(h) Other notices relevant to residents or visitors required by state or federal law.

This Rule is not met as evidenced by:

Based on observation, interview, and record review it was determined the facility failed to develop and conduct ongoing quality improvement programs that evaluated services, staff performance, resident outcomes, and resident satisfaction. Findings included, but are not limited to:

During the change of ownership survey, conducted 06/09/25 through 06/11/25, quality improvement oversight to ensure adequate resident care, services, satisfaction, and staff performance was found to be ineffective.

During an interview on 06/11/25 at 2:50 pm, Staff 1 (ED) and Staff 2 (MCC Administrator) confirmed the facility had not developed and implemented a quality improvement program.

Refer to the deficiencies in the report.

OAR 411-054-0025 (9) Facility Administration: Quality Improvement

(9) QUALITY IMPROVEMENT PROGRAM. The facility must develop and conduct an ongoing quality improvement program that evaluates services, resident outcomes, and resident satisfaction.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety, or welfare of residents. Findings include, but are not limited to:

The facility courtyard was toured on 06/09/25 and the following was observed:

* Several metal eye hooks were screwed into the concrete patio area in multiple areas where residents would be walking/standing/sitting. The eye hooks were approximately one inch above the concrete causing a potential tripping hazard.

The courtyard was toured with Staff 1 (ED) and Staff 2 (MCC Administrator) on 06/09/25 at 3:17 pm. They were unaware of the tripping hazard and acknowledged the eye hooks needed to be removed to ensure resident safety.

OAR 411-054-0025 (4) Reasonable Precautions

(4) Reasonable precautions must be exercised against any condition that could threaten the health, safety, or welfare of residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to immediately notify the local SPD office of any incident of suspected abuse for 1 of 1 sampled resident (#1) with reportable resident-to-resident altercations. Findings include, but are not limited to:

Resident 1 moved into the MCC in 10/2024 with diagnoses including Alzheimer’s disease.

Progress notes, incident and accident report forms (the tool used by the facility to investigate incidents), and interim service plans (ISP’s) were reviewed during the survey.

Resident 1 was involved in resident-to-resident altercations on the following dates:

* 02/23/25; and
* 03/12/25.

The altercations were not reported to the local SPD office as required. Survey requested the facility report the above incidents to the local SPD office. Verification was received on 06/11/25.

The need to ensure the facility immediately reported all physical altercations to the local SPD office as required was discussed with Staff 2 (MCC Administrator) on 06/11/25 at 2:15 pm. She 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 report to the local Seniors and People with Disabilities (SPD) office if abuse or neglect could not be ruled out for 1 of 1 sampled resident (# 4) who had a reportable incident. This is a repeat citation. Findings include, but are not limited to:

Resident 4 moved to the facility in 09/2025 with diagnoses including dementia. During the acuity interview on 10/01/25, Resident 4 was identified as requiring a two-person assist with transfers.

Observations of the resident, interviews with staff, and review of the resident's clinical record were completed and revealed the following:

A progress note dated 09/21/25 stated, “Caregiver told me that she had another caregiver assist her with getting [Resident 4] from [his/her] bed to wheelchair.” The progress note further stated Resident 4 had “called other caregiver fat during the transfer, and the 2nd caregiver gripped [Resident 4’s] arm instead of doing the correct under arm assist and quickly transferred [him/her] while [Resident 4] was crying out in pain, saying ouch repeatedly.” Following the transfer the caregiver stated she “noticed a skin tear to [his/her] right arm, which was the side that 2nd caregiver had transferred [him/her] by.”

On 09/23/25, a note by the facility nurse stated, “This nurse assessed residents [sic] skin tear that occurred on incident on the 21st while care staff were assisting resident. This nurse observed a quarter size skin tear and some moderate bruising around tear, purple in color.”

In an interview with Staff 2 (MCC Administrator) on 10/01/25 at 12:32 pm, she confirmed there was no documented evidence the incident had been reported to the local SPD office. This surveyor requested Staff 2 report the above incident to the local SPD office. Documentation was provided to the survey team confirming the incident had been reported to the local SPD office on 10/01/25 at 1:17 pm.

The need to ensure incidents were immediately reported to the local SPD office when needed was discussed with Staff 1 (ED) on 10/02/25 at 12:00 pm. She 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 interview and record review, it was determined the facility failed to ensure resident move-in evaluations addressed all required elements for 1 of 1 sampled resident (#3) whose move-in evaluation was reviewed. Findings include, but are not limited to:

Resident 3 moved into the MCC in 04/2025 with diagnoses including dementia.

The move-in evaluation failed to address the following elements:

* Personality: including how the person copes with change or challenging situations;
* Recent losses; and
* Environmental factors that impact the resident’s behavior including, but not limited to noise, lighting and room temperature.

Additional information was requested from Staff 2 (MCC Administrator) on 06/11/25 at 9:30 am. She reviewed the initial evaluation and acknowledged it failed to address all the required components.

OAR 411-054-0034 (1-6) Resident Move-in & Evaluation: Res Evaluation

(1) INITIAL SCREENING AND MOVE-IN.
(a) The facility must determine whether a potential resident meets the facility's admission requirements.
(b) Before the resident moving in, the facility must conduct an initial screening to determine the prospective resident's service needs and preferences. The screening must determine the ability of the facility to meet the potential resident's needs and preferences, while considering the needs of the other residents and the facility's overall service capability.
(c) Each resident record must, before move-in and when updated, include the following information:
(A) Legal name for billing purposes.
(B) To promote person-centered care, any variance from legal records, as indicated by the resident, regarding:
(i) Name.
(ii) Pronouns.
(iii) Gender identity.
(C) Prior living arrangements;
(D) Emergency contacts;
(E) Service plan involvement - resident, family, and social supports;
(F) Financial and other legal relationships, if applicable, including, but not limited to:
(i) Advance directives;
(ii) Guardianship; (iii) Conservatorship; and
(iv) Power of attorney.
(G) Primary language;
(H) Community connections; and
(I) Health and social service providers.

(2) RESIDENT EVALUATION - GENERAL. The resident evaluation identifies the resident's preferences, strengths, and relationships, as well as activities that are meaningful to the individual. The evaluation describes the resident's physical health status, mental status, and the environmental factors that help the individual function at their optimal level. The evaluation is the foundation that a facility uses to develop the resident's service plan. The evaluation information may be collected using tools and protocols established by the facility, but must contain the elements stated in this rule.
(a) Resident evaluations must be:
(A) Performed before the resident moves into the facility, with updates and changes as appropriate within the first 30 days; and
(B) Performed at least quarterly, to correspond with the quarterly service plan updates.
(C) Reviewed and any updates must be documented each time a resident has a significant change in condition.
(D) Done in person and the facility must gather data that is relevant to the needs and current condition of the resident.
(E) Documented, dated, and indicate who was involved in the evaluation process.
(b) 24 months of past evaluations must be kept in the resident's files in an accessible, on-site location. (c) The facility administrator is responsible for assuring only trained and experienced staff perform resident evaluations.

(3) EVALUATION REQUIREMENTS AT MOVE-IN.
(a) The resident evaluation must be completed before the resident moves into the facility. This evaluation provides baseline information of the resident's physical and mental condition at move-in.
(b) If there is an urgent need and the evaluation is not completed before move-in, the facility must document the reasons and complete the evaluation within eight hours of move-in.
(c) The initial evaluation must contain the elements specified in section (5) of this rule and address sufficient information to develop an initial service plan to meet the resident's needs.
(d) The initial evaluation must be updated and modified as needed during the 30 days following the resident's move into the facility.
(e) After the initial 30 day move-in period, the initial evaluation must be retained in the resident's file for 24 months. Future evaluations must be separate and distinct from the initial evaluation.

(4) QUARTERLY EVALUATION REQUIREMENTS.
(a) Resident evaluations must be performed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) The most recent quarterly evaluation, with documented change of condition updates, must be in the resident's current record and available to staff.
(d) If the evaluation is revised and updated at the quarterly review, changes must be dated and initialed and prior historical information must be maintained.

(5) The resident evaluation must address the following elements:
(a) For service planning purposes, if indicated by the resident,
(A) Name.
(B) Pronouns.
(C) Gender identity.
(b) Resident routines and preferences including:
(A) Customary routines, such as those related to sleeping, eating, and bathing;
(B) Interests, hobbies, and social and leisure activities;
(C) Spiritual and cultural preferences and traditions; and
(D) Additional elements as listed in 411-054-0027(2).
(c) Physical health status including:
(A) List of current diagnoses;
(B) List of medications and PRN use;
(C) Visits to health practitioners, emergency room, hospital, or nursing facility in the past year; and
(D) Vital signs if indicated by diagnoses, health problems, or medications.
(d) Mental health issues including:
(A) Presence of depression, thought disorders, or behavioral or mood problems;
(B) History of treatment; and (C) Effective non-drug interventions.
(e) Cognition, including:
(A) Memory;
(B) Orientation;
(C) Confusion; and
(D) Decision-making abilities.
(f) Personality, including how the person copes with change or challenging situations.
(g) Communication and sensory abilities including:
(A) Hearing;
(B) Vision;
(C) Speech;
(D) Use of assistive devices; and
(E) Ability to understand and be understood.
(h) Activities of daily living including:
(A) Toileting, bowel, and bladder management;
(B) Dressing, grooming, bathing, and personal hygiene;
(C) Mobility - ambulation, transfers, and assistive devices; and
(D) Eating, dental status, and assistive devices.
(i) Independent activities of daily living including:
(A) Ability to manage medications; (B) Ability to use call system;
(C) Housework and laundry; and
(D) Transportation.
(j) Pain - pharmaceutical and non-pharmaceutical interventions, including how a person expresses pain or discomfort.
(k) Skin condition.
(l) Nutrition habits, fluid preferences, and weight if indicated.
(m) List of treatments - type, frequency, and level of assistance needed.
(n) Indicators of nursing needs, including potential for delegated nursing tasks.
(o) Review of risk indicators including:
(A) Fall risk or history;
(B) Emergency evacuation ability;
(C) Complex medication regimen;
(D) History of dehydration or unexplained weight loss or gain;
(E) Recent losses;
(F) Unsuccessful prior placements;
(G) Elopement risk or history;
(H) Smoking. The resident's ability to smoke without causing burns or injury to themselves or others or damage to property must be evaluated and addressed in the resident's service plan; and
(I) Alcohol and drug use. The resident's use of alcohol or the use of drugs not prescribed by a physician must be evaluated and addressed in the resident's service plan.
(p) Environmental factors that impact the resident's behavior including, but not limited to:
(A) Noise.
(B) Lighting.
(C) Room temperature.
(6) If the information has not changed from the previous evaluation period, the information does not need to be repeated. A dated and initialed notation of no changes is sufficient. The prior evaluation must then be kept in the current resident record for reference.

Stat. Auth.: ORS 410.070, 441.122, 443.450
Stats. Implemented: ORS 441.111, 441.114, 443.400-443.455, 443.991

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were implemented for 1 of 2 sampled residents (#1) whose service plan was reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC with diagnoses including Alzheimer’s disease.

Observations of the resident, interviews with staff, and review of the service plan, dated 03/18/25, and subsequent interim service plans (ISP’s) identified the service plan was not implemented in the following areas:

* Provide Ensure supplement drink three times per day;
* Offer handheld foods during meals; and
* Cueing to maintain adequate intake.

The need to ensure staff were implementing the service plan was discussed with Staff 2 (MCC Administrator) on 06/11/25 at 2:15 pm. She acknowledged the findings.

OAR 411-054-0036 (1-4) Service Plan: General

(1) If the resident has a Person-Centered Service Plan pursuant to 411- 004-0030, the facility must incorporate all elements identified in the person centered service plan into the resident's service plan.

(2) SERVICE PLAN.
The service plan must reflect the resident's needs as identified in the evaluation and include resident preferences that support the principles of dignity, privacy, choice, individuality, and independence.
(a) The service plan must be completed: (A) Before resident move-in, with updates and changes as appropriate within the first 30-days; and (B) Following quarterly evaluations.
(b) The service plan must be readily available to staff and provide clear direction regarding the delivery of services.
(c) The service plan must include a written description of who shall provide the services and what, when, how, and how often the services shall be provided.
(d) Changes and entries made to the service plan must be dated and initialed.
(e) When the resident experiences a significant change of condition the service plan must be reviewed and updated as needed.
(f) A copy of the service plan, including each update, must be offered to the resident or to the resident's legal representative.
(g) The facility administrator is responsible for ensuring the implementation of services.
(h) Changes to the service plan, including updates due to a significant change of condition and quarterly updates must be reflected in the facility’s ABST care elements.

(3) SERVICE PLAN REQUIREMENTS BEFORE MOVE-IN.
(a) Based on the resident evaluation performed before move-in, an initial service plan must be developed before move-in that reflects the identified needs and preferences of the resident.
(b) The initial service plan must be reviewed within 30-days of movein to ensure that any changes made to the plan during the initial 30- days, accurately reflect the resident's needs and preferences.
(c) Staff must document and date adjustments or changes as applicable.

(4) QUARTERLY SERVICE PLAN REQUIREMENTS.
(a) Service plans must be completed quarterly after the resident moves into the facility.
(b) The quarterly evaluation is the basis of the resident's quarterly service plan.
(c) If the resident's service plan is revised and updated at the quarterly review, changes must be dated and initialed, and prior historical information must be maintained.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure delegation and supervision of special tasks of nursing care was completed in accordance with Oregon State Board of Nursing (OSBN) Division 47 rules, for 1 of 1 sampled resident (#2) who received insulin injections by unlicensed facility staff. Findings include, but are not limited to:

According to OSBN Division 47 Administrative Rules, delegation means an RN authorizes an unlicensed person to perform tasks of nursing care and indicates the authorization in writing. The delegation process includes nursing assessment of the client in a specific situation, evaluation of the ability of the unlicensed persons, teaching the task, and observing the staff demonstrate the task.

During the acuity interview on 06/09/25, Resident 2 was identified to be administered insulin injections by non-licensed staff.

Resident 2’s MARs, reviewed from 05/01/25 through 06/09/25, revealed the resident received insulin (to treat diabetes) twice daily. The insulin had been given by Staff 13 and 16 (MTs) on multiple occasions.

Review of initial delegation records for Staff 13 (delegated on 02/05/25) and 16 (delegated on 05/06/25) revealed the following:

a. There was no documentation by the RN verifying that all requirements from the initial delegation were met.
b. There was no documentation the RN addressed questions Staff 13, Staff 16, or the resident may have had.
c. There was no evidence the RN evaluated the frequency the resident should be reassessed based on their assessed baseline and health problems that may impact the resident’s condition related to the delegated nursing procedure.

Review of periodic inspection records for Staff 13 showed the following:

a. The reauthorization for Staff 13, dated 06/08/25, did not occur prior to the end of the initial delegation period.
b. There was no documentation by the RN verifying that all requirements from the delegation were met.
c. There was no documentation the RN verified Staff 13’s documentation, observed her performance of the procedure, or addressed questions or concerns Staff 13 or the resident might have had.
d. There was no documentation of the length of authorization period.

The requirements for delegation were reviewed with Staff 3 (RN of Delegation and Wellness) on 06/11/25. She acknowledged the findings.

The need to ensure all staff who administered insulin injections were appropriately delegated and supervised in accordance with OSBN Administrative Rules was discussed with Staff 2 (MCC Administrator) on 06/11/25 at 2:40 pm. She acknowledged the findings.

OAR 411-054-0045 (1)(f)(B) RN Delegation and Teaching

(1) RESIDENT HEALTH SERVICES. The facility must provide health services and have systems in place to respond to the 24-hour care needs of residents. The system must:(B) Delegation and Teaching. Delegation and teaching must be provided and documented by a RN in accordance with the Oregon Administrative Rules adopted by the Oregon State Board of Nursing in chapter 851, division 047.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure written, signed physician or other legally recognized practitioner orders were carried out as prescribed for 1 of 2 sampled residents (#1) whose orders were reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 10/2024 with diagnoses including Alzheimer’s disease and attention deficit/hyperactivity disorder (ADHD).

The resident's 05/01/25 to 06/09/25 MARs and prescriber orders were reviewed and identified the following medication order was not carried out as prescribed:

* Mirtazapine 15 mg tablet daily prescribed for ADHD was discontinued on 05/22/25; and
* Facility staff continued to administer the medication until 05/27/25, six more doses.

The need to ensure written, signed physician or other legally recognized practitioner orders were carried out as prescribed was discussed with Staff 2 (MCC Administrator) on 06/11/25 at 2:15 pm. She acknowledged the findings.

OAR 411-054-0055 (1)(f-h) Systems: Treatment Orders

(f) Medication and treatment orders must be carried out as prescribed.(g) Written, signed physician or other legally recognized practitioner orders must be documented in the resident's facility record for all medications and treatments that the facility is responsible to administer.(h) Only a physician or other legally recognized prescribing practitioner is authorized to make changes in a medication or treatment order.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate for 1 of 2 sampled residents (#2) whose medications were reviewed. Findings include, but are not limited to:

Resident 2 was admitted to the MCC in 2022 with diagnoses which included insulin-dependent diabetes.

Residents 2's MARs were reviewed from 05/01/25 through 06/09/25 and the following was noted:

* Resident 2 had orders for sliding scale insulin once a day. Staff were to administer 23 units every morning with breakfast if the CBG was less than 100. If CBG was 100 or greater, staff were to administer 33 units.

According to the MAR, staff documented the daily CBG and initialed that insulin was given. However, staff did not document whether 23 units or 33 units were administered.

In an interview on 06/11/25 at 9:00 am, Staff 16 (MT) stated the correct amount of insulin was administered but not documented.

The MAR errors were reviewed with Staff 3 (RN of Delegation and Wellness) on 06/11/25 at 9:05 am. She stated the MTs should have documented the amount of insulin given.

The need for the facility to ensure MARs were accurate was discussed with Staff 2 (MCC Administrator) on 06/11/25 at 2:40 pm. She acknowledged the findings. No further information was provided.

OAR 411-054-0055 (2) Systems: Medication Administration

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

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure 3 of 4 direct care staff (#s 11, 13, and 19) had documented evidence of completion of First Aid and abdominal thrust training within 30 days of hire. Findings include, but are not limited to:

Staff training records, reviewed on 06/10/25, revealed Staff 11 (MT/CG), hired 03/17/25, Staff 13 (MT), hired 01/15/25, and Staff 19 (CG), hired 03/31/25, lacked documented evidence they had completed First Aid and Abdominal Thrust training.

The need to ensure staff demonstrated competency in assigned job duties within 30 days of hire was discussed with Staff 2 (MCC Administrator) on 06/10/25. She acknowledged the findings. No further information was provided.

OAR 411-054-0070 (5 & 9-10) Training Within 30 Days of Hire – Direct Care Staff

(5) TRAINING WITHIN 30 DAYS OF HIRE FOR DIRECT CARE STAFF.
(a) The facility is responsible to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned.
(b) Knowledge and performance must be demonstrated in all areas within the first 30 days of hire, including, but not limited to:
(A) The role of service plans in providing individualized resident care.
(B) Providing assistance with the activities of daily living.
(C) Changes associated with normal aging.
(D) Identification of changes in the resident's physical, emotional and mental functioning and documentation and reporting on the resident's changes of condition.
(E) Conditions that require assessment, treatment, observation and reporting.
(F) General food safety, serving and sanitation.
(G) If the direct care staff person’s duties include the administration of medication or treatments, appropriate facility staff, in accordance with OAR 411-054-0055 (Medications and Treatments) must document that they have observed and evaluated the individual’s ability to perform safe medication and treatment administration unsupervised.

(9) ADDITIONAL REQUIREMENTS. Staff:
(a) Under 18 years of age may not perform medication administration or delegated nursing tasks. Staff under the age of 18 must be directly supervised when providing bathing, toileting, incontinence care or transferring services.
(b) Must be trained in the use of the abdominal thrust and First Aid. Cardiopulmonary resuscitation (CPR) training is recommended, but not required.
(c) Must have sufficient communication and language skills to enable them to perform their duties and communicate with residents, other staff, family members, and health care professionals, as needed.

(10) Contractors who provide services or supports directly to residents must complete the required LGBTQIA2S+ trainings outlined in paragraph (6)(b)(C) of this rule.
(a) Contractors who must be trained include, but are not limited to, RN and administrative consultants, housekeeping services, dietary services, beauticians, barbers, or other contractors who provide services or supports directly to residents.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct fire drills in accordance with the Oregon Fire Code (OFC) and have a written fire drill record that documented all required components of a fire drill. Findings include, but are not limited to:

Fire and life safety records dated 12/2024 through 05/2025 were reviewed with Staff 2 (MCC Administrator) on 06/10/25 at 2:30 pm. The following was identified:

a. Unannounced fire drills were not being conducted and recorded every other month at different times of the day, evening, and night shifts within the memory care.
b. There was no documented evidence staff provided fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction.
c. The written fire drill records failed to document the following required components:
* Problems encountered and comments relating to residents who resisted or failed to participate in the drills;
* Evacuation time period needed;
* Staff members on duty and participating in the drill; and
* The number of occupants that were evacuated.

The need to ensure fire drill records documented all required components of a fire drill as required by the OFC and the facility provided evacuation assistance to residents from the building to a designated point of safety was discussed with Staff 2 on 06/10/25 at 2:30 pm. She acknowledged the findings.

OAR 411-054-0090 (1-2) Fire and Life Safety: Safety

(1) FIRE DRILLS. All fire drills shall be conducted according to the Oregon Fire Code (OFC). (a) Unannounced fire drills must be conducted and recorded every other month at different times of the day, evening, and night shifts. (b) Fire and life safety instruction to staff must be provided on alternate months. (c) The Fire Authority may develop an alternative fire drill plan for the facility. Any such plan must be submitted to the Department. (d) A written fire drill record must be kept to document fire drills that include: (A) Date and time of day; (B) Location of simulated fire origin; (C) The escape route used; (D) Problems encountered and comments relating to residents who resisted or failed to participate in the drills; (E) Evacuation time period needed; (F) Staff members on duty and participating; and (G) Number of occupants evacuated. (e) Alternate exit routes must be used during fire drills to react to varying potential fire origin points. (f) The evacuation capability of the residents and staff is a function of both the ability of the residents to evacuate and the assistance provided by the staff. (g) Staff must provide fire evacuation assistance to residents from the building to a designated point of safety as determined by the Fire Authority having jurisdiction. Points of safety may include, outside the building, through a horizontal exit, or other areas as determined by the Fire Authority having jurisdiction. (h) The fire alarm system shall be activated during each fire drill, unless otherwise directed by the Fire Authority having jurisdiction. (2) If the facility is unable to meet the applicable evacuation level, the facility must make an immediate effort to make changes to ensure the evacuation standard is met. Changes must include, but not be limited to: (a) Increasing staff levels, (b) Changing staff assignments, (c) Requesting change in resident rooms, and (d) Arranging for special equipment. After making necessary changes, if the facility fails to meet the applicable evacuation level, the facility must issue an involuntary move-out notice to the residents in accordance with OAR 411-054-0080.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to ensure residents were instructed on general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places inside or outside the building within 24 hours of admission and failed to re-instruct residents on fire and life safety at least annually, with a written record of the content of the training sessions and the residents attending, per the Oregon Fire Code (OFC). Findings include, but are not limited to:

Facility fire drill and fire and life safety records from 12/2024 to 05/2025 were requested and reviewed with Staff 2 (MCC Administrator) on 06/10/25 at 2:30 pm.

During the review of the fire drill records Staff 2 reported the facility does not have documentation that residents were instructed on general fire safety procedures within 24 hours of admission and the facility does not have a system for annual re-instruction of general safety procedures.

The need to instruct residents of general fire safety procedures within 24 hours of admission and re-instruct residents at least annually per the OFC requirements was discussed with Staff 2 on 06/10/25 at 2:30 pm. She acknowledged the findings.

OAR 411-054-0090 (5) Fire and Life Safety: Training for Residents

(5) TRAINING FOR RESIDENTS. Residents must be instructed about the facility's fire and life safety procedures per OFC. (a) Each resident must be instructed within 24 hours of admission and re-instructed, at least annually, in general safety procedures, evacuation methods, responsibilities during fire drills, and designated meeting places outside the building or within the fire safe area in the event of an actual fire. This requirement does not apply to residents whose mental capability does not allow for following such instruction. (b) A written record of fire safety training, including content of the training sessions and the residents attending, must be kept.

This Rule is not met as evidenced by:

Based on interview and record review, it was determined the facility failed to conduct a drill of the emergency preparedness plan at least twice a year. Findings include, but are not limited to:

On 06/10/25 at 2:30 pm, survey requested Staff 2 (MCC Administrator) provide documentation of emergency preparedness drills conducted at the facility over the previous 12 months.

During an interview on 06/11/25 at 9:35 am, Staff 2 was unable to explain or provide documentation that included analysis and response to potential emergencies, including but not limited to, the evacuation of the facility. Staff 2 confirmed the facility had not conducted drills for the emergency preparedness plan at least twice a year.

The need to ensure the facility conducted a drill of the emergency preparedness plan at least twice a year was reviewed with Staff 1 (ED) and Staff 2 on 06/11/25 at 2:15 pm. She acknowledged the findings.

OAR 411-054-0093 (1-5) Emergency and Disaster Planning

An emergency preparedness plan is a written procedure that identifies a facility's response to an emergency or disaster for the purpose of minimizing loss of life, mitigating trauma, and to the extent possible, maintaining services for residents, and preventing or reducing property loss.
(1) The facility must prepare and maintain a written emergency preparedness plan in accordance with the OFC.

(2) The emergency preparedness plan must:
(a) Include analysis and response to potential emergency hazards including but not limited to:
(A) Evacuation of a facility;
(B) Fire, smoke, bomb threat, or explosion;
(C) Prolonged power failure, water, or sewer loss;
(D) Structural damage;
(E) Hurricane, tornado, tsunami, volcanic eruption, flood, and earthquake;
(F) Chemical spill or leak; and
(G) Pandemic.
(b) Address the medical needs of the residents including:
(A) Access to medical records necessary to provide care and treatment; and
(B) Access to pharmaceuticals, medical supplies, and equipment during and after an evacuation.
(c) Include provisions and supplies sufficient to shelter in place for a minimum of three days without electricity, running water, or replacement staff.

(3) The facility must notify the Department, the local AAA office, or designee, of the facility's status in the event of an emergency that requires evacuation and during any emergent situation when requested.

(4) The facility must conduct a drill of the emergency preparedness plan at least twice a year in accordance with the OFC and other applicable state and local codes as required. One of the practice drills may consist of a walk-through of the duties or a discussion exercise with a hypothetical event, commonly known as a tabletop exercise. These simulated drills may not take the place of the required fire drills.

(5) The facility must annually review or update the emergency preparedness plan as required by the OFC and the emergency preparedness plan must be available on-site for review upon request.

This Rule is not met as evidenced by:

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

Refer to C231.

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 observation and interview, it was determined the facility failed to ensure exterior grounds were orderly and free of litter or refuse. Findings include, but are not limited to:

The facility courtyard was toured on 06/09/25 and the following was observed:

* Trash debris, broken pots, and a dirty fabric chair cushion littered the courtyard area.

The building exterior was toured with Staff 1 (ED) and Staff 2 (MCC Administrator) on 06/09/25 at 3:17 pm. They acknowledged the findings.

OAR 411-054-0200 (3) General Building Exterior

(3) GENERAL BUILDING EXTERIOR.(a) All exterior pathways and accesses to the RCF common-use areas, entrance, and exit ways must be made of hard, smooth material, be accessible, and maintained in good repair.(b) A RCF must take measures to prevent the entry of rodents, flies, mosquitoes, and other insects. There must be locked storage for all poisons, chemicals, rodenticides, and other toxic materials. All materials must be properly labeled.(c) RCF grounds must be kept orderly and free of litter and refuse. Garbage must be stored in covered refuse containers.(d) As described in OAR 411, division 057, memory care communities licensed as a RCF must be located on the ground floor. A CF cannot be endorsed as a memory care community.(e) A RCF must provide storage for all maintenance equipment, including yard maintenance tools, if not provided by a third-party contract.(f) A RCF must provide an accessible outdoor recreation area. The outdoor recreation area must be available to all residents. Lighting must be equal to a minimum of five foot candles. Memory Care Communities must provide residents with direct access to a secure outdoor recreation area as described in OAR chapter 411, division 057.(g) Outdoor perimeter fencing may not be secured to prevent exit unless the RCF has written approval from the Department for an exception or the RCF is in compliance with OAR chapter 411, division 057 (Memory Care Communities) or OAR 309-019-0100 through 309-019-0220.(h) A RCF must have an entry and exit drive to and from the main building entrance that allows for a vehicle to pick up and drop off residents and mail deliveries without the need for vehicles to back up.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the environment was kept clean and in good repair. Findings include, but are not limited to:

Observations of the facility on 06/09/25 revealed the following:

* Rooms 104, 106, 200, 209, and 213 had scraped doors and/or jambs;
* Several walls in the dining rooms had scrapes;
* Multiple handrails throughout had areas of scraped, peeling paint;
* The handrail near Room 104 was loose and coming apart from the wall;
* Several baseboards throughout were gouged and scraped;
* Carpet in multiple sitting areas had areas of black stains;
* A pillar and several walls in the television area had multiple scraped and gouged areas;
* The laundry room (near the kitchenette) was observed with laundry on the floor, a cleaning bucket with a dirty mop head in it, sink with soiled clothing protectors in the basin, trash/debris between the washer and dryer, and dust/lint/trash debris on the floor throughout; and
* The laundry room (near the television area) had scraped walls and door edge, the backsplash was missing behind the sink, the sink basin had brown liquid and stains, open beverage cans sat on the counter next to the sink, dust/lint/trash debris littered the floor throughout, and the ceiling vent had an accumulation of dust.

The surveyor toured the environment with Staff 1 (ED) and Staff 2 (MCC Administrator) on 06/09/25 at 3:15 pm. They acknowledged the above areas needed to be cleaned and repaired.

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.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure each individual had privacy in his or her own unit for multiple unsampled residents who shared bathrooms. Findings include, but are not limited to:

During an observation and interview on 06/09/25 at 1:42 pm with Staff 10 (CG), a shared bathroom was observed to have a deadbolt lock on the outside of the door with no way to lock the door from the inside for privacy. Staff 10 reported none of the bathrooms except the common area bathrooms had locks on the doors.

In an interview at 9:17 am on 06/10/25, Staff 2 (MCC Administrator) confirmed all bathroom doors, including the shared bathrooms in the double occupancy units, did not have a locking mechanism.

The need to ensure privacy in individual resident units was discussed with Staff 2 on 06/10/25 at 9:17 am. The findings were acknowledged.

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 residents who lived in the facility were provided a key to their unit for 1 of 2 sampled residents (#1) and multiple unsampled residents. Findings include, but are not limited to:

Review of Resident 1’s record identified there was no documented evidence the resident had been provided a key to his/her room.

During an interview on 06/10/25 at 9:17 am, Staff 2 (MCC Administrator) confirmed Resident 1 had not been provided a key to his/her unit, as well as multiple unsampled residents. Staff 2 reported only three residents had keys to their rooms.

The need to ensure all residents were provided keys to their units was discussed with Staff 2 on 06/10/25 at 9:17 am. She acknowledged the findings.

OAR411-004-0020(2)(e) Individual Door Locks: Key Access

(2) Provider owned, controlled, or operated residential settings must have all of the following qualities:
(e) Units must have entrance doors lockable by the individual, with the individual and only appropriate staff having a key to access the unit.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to ensure the LGBTQIA2S+ Nondiscrimination Notice was posted in a routinely accessible and conspicuous location to residents and visitors and were available for inspection. Findings include, but are not limited to:

Refer to C152.

OAR 411-054-0025 (5)(f)(g) Facility Administration: Required Postings

(5) REQUIRED POSTINGS. Required postings must be posted in a routinely accessible and conspicuous location to residents and visitors and must be available for inspection at all times. The licensee is responsible for posting the following:

(f) Resident Rights and Protections, as described in OAR 411-054- 0027, including the LGBTQIA2S+ Rights and Protections.

(g) The LGBTQIA2S+ Nondiscrimination Notice, as described in paragraph (7)(i) of this section, must be posted in all places and on all materials where that notice or those written materials are posted.

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 C 150, C 152, C 156, C 160, C 231, C 372, C 420, C 422, C 435, C 510, and C 513.

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. This is a repeat citation. Findings include, but are not limited to:

Refer to C231.

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 interview and record review, it was determined the facility failed to ensure 1 of 4 newly hired direct care staff (#11) completed all required pre-service orientation and dementia training topics prior to beginning job duties, and 4 of 4 newly hired direct care staff (#s 11, 13, 15, and 19) demonstrated competency in all job duties within 30 days of hire. Findings include, but are not limited to:

Staff training records, reviewed with Staff 5 (Business Office Manager) on 06/10/25, revealed the following:

a. There was no documented evidence Staff 11 (MT/CG), hired 03/17/25, completed one or more of the following pre-service orientation topics prior to beginning their job duties:

* Resident rights and values of CBC care;
* Abuse reporting requirements;
* Infectious Disease Prevention;
* Fire safety and emergency procedures;
* Approved HCBS course; and
* Approved LGBTQIA2S+ course.

b. There was no documented evidence Staff 11 (MT/CG) completed the required pre-service dementia care topics.

c. There was no documented evidence Staff 11 (MT/CG), 13 (MT), 15 (CG), and 19 (CG) demonstrated competency in one or more assigned duties within 30 days of hire, including:

* Role of service plans in providing individualized care;
* Providing assistance with ADLs;
* Changes associated with normal aging;
* Identification, documentation, and reporting changes of condition;
* Conditions which require assessment, treatment, observation, and reporting; and
* General food safety, serving, and sanitation.

d. Training records revealed no documented competency in medication administration for Staff 11 and 13. The surveyor informed Staff 5 (Business Office Manager) that Staff 11 and 13 could not administer medications until documented training was completed. He acknowledged and stated he would ensure documented medication training was completed for Staff 11 and 13 before they administered medications.

The need to ensure all required staff trainings were completed in the required time frames was discussed with Staff 2 (MCC Administrator) on 06/10/25. She acknowledged the findings. No further information was provided.

OAR 411-057-0155(1-6) Staff Training Requirements

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

This Rule is not met as evidenced by:

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 252, C 260, C 282, C 303, and C 310.

OAR 411-057-0160(2b) Compliance with Rules Health Care

(b) Health care services provided in accordance with the licensing rules of the facility.

This Rule is not met as evidenced by:

Based on observation, interview, and record review, it was determined the facility failed to ensure a daily meal program for nutrition and hydration was provided based upon the resident’s preferences and needs and ensured the individualized nutritional plan was documented in the resident’s service plan for 1 of 2 sampled residents (#1) whose service plans were reviewed. Findings include, but are not limited to:

Resident 1 moved into the MCC in 10/2024 with diagnoses including Alzheimer’s disease and had a history of weight loss.

Resident 1’s service plan, dated 03/18/25, was reviewed during the survey, observations were made, and staff interviews were conducted. The following was identified:

During the lunch meal observation on 06/10/25, from 12:00 pm to 12:40 pm, the resident was served soup, macaroni, salmon, edamame, and cooked zucchini. The resident ate four pieces of edamame and three slices of cooked zucchini. The resident avoided using the spoon and fork provided. S/he attempted to pick up the macaroni with his/her hand and then stopped to wipe the food off his/her hand. The resident repeated this three times before getting up from the table and walking away. Staff did not provide encouragement or cueing to finish his/her meal.

During an interview on 06/10/25 at 12:48 pm, Staff 13 (MT) reported Resident 1 had protein bars that s/he could easily hold and walk around with. Staff 13 stated the protein bars were kept in the medication room; however, Staff 13 was not aware of when the protein bars should be provided.

During breakfast meal service on 06/11/25 at 10:08 am, an observation with Staff 2 (MCC Administrator) confirmed Resident 1 was provided with a glass of water, scrambled eggs, cubed potatoes, and a small bowl of green grapes. There were a couple pieces of potatoes eaten off the plate. The scrambled eggs and grapes were not eaten, and there was a fork and spoon next to the plate that were unused. Staff did not encourage or cue him/her back to the dining room to finish eating.

The service plan instructed staff to provide handheld food; however, there was no information on the resident’s service plan regarding preferred foods, including foods that were handheld, or when staff were to provide the resident with a protein bar.

Resident 1’s service plan lacked an individualized nutrition and hydration plan.

The need to ensure an individualized nutrition and hydration plan that was based on the resident’s preferences and needs was developed and included in the resident’s service plan was discussed with Staff 2 on 06/11/25 at 10:08 am. She acknowledged the findings.

Refer to C260.

OAR 411-057-0160(2)(c)(A)(B) Nutrition and Hydration

(c) A daily meal program for nutrition and hydration must be provided based upon the resident ' s preferences and needs available throughout each resident ' s waking hours. The individualized nutritional plan for each resident must be documented in the resident ' s service or care plan. In addition, the memory care community must provide: (A) Visual contrast between plates, eating utensils, and the table to maximize the independence of each resident; and (B) Adaptive eating utensils for those residents who have been evaluated as needing them to maintain their eating skills.

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance. Findings include, but are not limited to:

During a tour of the secure courtyard on 06/09/25, it was observed the door entering and returning from the courtyard was locked. This prevented residents from accessing the courtyard without staff assistance, both going outside and returning indoors.

In an interview with Staff 13 (MT) on 06/09/25 at 9:15 am, she said the door was always locked to “prevent residents from going outside and getting hurt or falling.”

During a tour of the courtyard with Staff 1 (ED) and Staff 2 (MCC Administrator) on 06/09/25 at 3:15 pm, they confirmed the door was always locked. Staff 1 stated she was unsure how to disengage the door lock to allow residents to access the courtyard without staff assistance and would inquire with the management company.

The need to provide access to a secured outdoor space and walkways which allowed residents to enter and return without staff assistance was discussed with Staff 2 on 06/11/25. She acknowledged the findings.

OAR 411-057-0160(g) Outside Area

(g) Access to secured outdoor space and walkways which allow residents to enter and return without staff assistance, except when indicated by OAR 411-057-0170(5)(e).

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to have a written facility policy which detailed when doors to the outdoor recreation area may be locked during nighttime hours or during severe weather. Findings include, but are not limited to:

During the survey, the door to the courtyard was observed to be locked.

During an interview with Staff 2 (MCC Administrator) on 06/11/25 at 11:55 am, she reported the courtyard doors were always locked, and residents could access the courtyard by asking care staff to unlock the door. She added that the facility did not have a written policy which detailed when doors to the outdoor courtyard area may be locked.

The need to ensure the facility had a written policy which described under what circumstances the doors to the courtyard would be locked was reviewed with Staff 1 (ED) and Staff 2 during the exit interview. They acknowledged the findings.

OAR 411-057-0170(6) Secure Outdoor Recreation Area

(6) SECURE OUTDOOR RECREATION AREA. The memory care community must comply with facility licensing requirements for outdoor recreation areas as well as the following standards. These requirements apply to newly endorsed, constructed, or remodeled communities which have construction documents approved on or after November 1, 2010 with the exception of subsections (d) and (e) of this section. (a) The space must be a minimum of 600 square feet or 15 square feet per resident, whichever is greater and is exclusive of normal walkways and landscaping. The space must have a minimum dimension of 15 feet in any direction; (b) Fences surrounding the perimeter of the outdoor recreation area must be no less than six feet in height, constructed to reduce the risk of resident elopement, and maintained in functional condition; (c) Walkways must meet the accessibility requirements of the Oregon Structural Specialty Code. Walkway surfaces must be a medium to dark reflectance value to prevent glare from reflected sunlight; (d) Outdoor furniture must be sufficient weight, stability, design, and be maintained to prevent resident injury or aid in elopement; and (e) Doors to the outdoor recreation area may be locked during nighttime hours or during severe weather per facility policy.

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 facility kitchen was reviewed on 11/12/24 from 10:40 am through 3:00pm and memory care unit during lunch service from 11:15pm thru 1:15 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:

* Reach in coolers;
* Walk in cooler floor;
* Walk in cooler metal racks;
* Walk in cooler fan blades/cages and ceiling;
* Walk in freezer floor;
* Interior of ice machine;
* Kitchen drains;
* Floors under, behind and between equipment;
* Legs and wheels of large equipment;
* Interior and exterior of microwaves;
* Industrial can opener and housing;
* Griddle top and sides;
* Interior of cabinet where clean plates were stored;
* Ceiling vents above food prep areas;
* Floors throughout kitchen in corners and edges;
* Walls behind cooking areas;
* Walls and floors behind and underneath dish machine;
* Top and sides of dish machine;
* Interior of metal and wood drawers;
* Sprinkler heads;
* Utility racks;
* Utility carts;
* Juice machine;
* Counter tops throughout kitchen;
* Metal shelving storing spices;
* Industrial slicer
* Industrial Mixer and table holding mixer;
* Memory care unit reach in refrigerator and freezer;
* Interior of memory care microwave;

b. The following areas were in need of repair:

* Caulking by dish machine area with black debris build up.
* Multiple sprinkler heads with heavy dust/grease build up.
* Area on steam line with green duct tape.
* Dish machine with scale build up on sides/top and interior;
* Ice machine with significant black debris build up on interior;
* Reach in refrigerator in memory care unit with cracks to plastic shelving;

c. Multiple food items found in walk in cooler, reach in coolers, walk in freezer and reach in freezer not covered and exposed to potential contamination. Sliced lemon noted in memory care refrigerator not wrapped or covered exposing it to potential contamination.

d. Multiple prepared food items found past seven days. Multiple potentially hazardous food items not dated when opened and/or prepared.

e. Multiple staff noted to be handling clean dishes and/or preparing/serving food without facial hair restraints as required.

f. Staff drinks were observed stored in food preparation areas and did not contain lids/straws/handles to minimize hand/lip contact as required.

g. Multiple food items found in dry storage stored open to potential contamination.

h. Single service utensils were observed stored open and exposed to potential contamination.

i. Multiple potentially hazardous food items found stored in walk in refrigerator stacked on top of each other with visible drippings in a pan. Not all items were of the same meat and were not separately contained as required.

j. Person In Charge (PIC) Staff 2 (Director of Dining Services) was interviewed at 12:45pm and was not able to correctly state proper reheat procedures or temperatures needed to ensure food was safely heated to 165 degrees as required.

k. In the walk in, several turkeys were observed on sheet pans thawing. They were open to potential contamination. The turkeys did not have any dates as to when those items were pulled to begin their thawing process.

l. Multiple staff in memory care were did not done aprons during meal service to protect from potential cross contamination from care tasks and meal service.

m. Multiple care staff in memory care until were observed to potentially contaminate gloves during meal service (touching face/hair, or touching handles of drawers/carts/refrigerator then serve drinks, handle utensils for and to residents.

On 11/12/24 at 1:15pm Staff 2 (Dining Services Director) was informed of the identified concerns and areas in need of correction. Staff 2 acknowledged areas.

At 2:30 pm areas identified were reviewed with staff 1 (LPN of Health and Wellness) who acknowledged 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:

Z 142: Based on observations and interviews, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:

Refer to C240.

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 interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to ensure resident records are kept for a minimum of three years after the resident is no longer in the facility. Findings include, but are not limited to:In an interview on 04/01/24, Staff 1 (Executive Director) stated the facility had a change of ownership and management in October of 2023. S/he stated the records from the previous ownership are incomplete and what they do have is unorganized in boxes. The facility was unable to provide documentation for several residents that were requested.The facility did not ensure resident records were maintained during the transfer of ownership in October 2023.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Verbal Plan of Correction: The concierge was to spend a couple days a week to organize the archive room and label bankers boxes with names to make files easier to locate.

Based on observation and interview, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to provide 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 and ensure food is prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules). Findings include, but are not limited to:On 04/01/24 at 12:03 Resident 10 was observed to be served a regular lunch, but with no meat as the other residents were observed to have. Resident was not observed to be offered the alternative taco soup that was available.On 04/04/24 at 8:00 am Resident 10 was served a regular texture meal, but the breakfast sausage was observed to be withheld. No alternative protein was observed to be offered.In an interview on 04/04/24 Staff 8 (Caregiver) stated s/he removed the meat from Resident 10's lunch because it was dry and tough and s/he didn't want Resident 10 to choke. S/he did not know how the resident would get protein.On 04/04/24 at 7:08 am the kitchenette was observed. There was an open milk jug in the refrigerator with no lid and an open energy drink. There was cottage cheese, lettuce, cantaloupe and mandarin oranges in the food storage containers with no dates. Several individual servings of food in Styrofoam containers were unlabeled and undated. An open basket of leftover food with no lid and no date was also observed.In an interview on 04/04/24, Staff 4 (Administrator) stated s/he was not sure when any of the food was put in the fridge and was unaware things should be labeled and dated. The facility failed to provide 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 and ensure food is prepared and served in accordance with OAR 333-150-0000 (Food Sanitation Rules).The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction - Administrator ensured fridge was to be deep cleaned, equipped with thermometer and temperature sheet. Care staff received instructions to label with open and discard dates. This was to be monitored by Administrator. A dietary binder with image of residents and dietary restriction had been created and would be available in kitchenette for staff.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to be responsible for ensuring the implementation of services for 2 of 2 sampled residents (#'s 1 and 10). Findings include, but are not limited to:a. Resident 1's service plan dated 02/08/24 indicated the following:· In mobility/ambulation Resident 1 totally dependent on staff for all mobility needs. S/he was non-ambulatory. Staff were to escort him/her to/from meals, activities and his/her room.· In Escorts moderate level of assistance. Resident 1 may required escorts and required an assistive device for mobility/ambulation.· In Meal consumption Resident 1 required moderate assistance, cutting up of food, opening cartons/packages; may have needed encouragement to select menu items. Resident was on a regular diet.· An Interim Service Plan for Resident 1 dated 01/18/24 indicated resident had a diet change to a puree diet with thin liquids and required assistance with providing meals.In an interview on 04/01/24, Staff 8 (Caregiver) stated Resident 1 had a mechanical soft diet, and required full feeding assistance, because s/he was unable to feed him/herself. Resident required full assistance with transferring and escorts.During the noon meal on 04/01/24 Resident 1 was observed to be fed a pureed meal.At 9:10 am on 04/04/24 staff were observed to wake and transfer Resident 1 into his/her wheelchair and escort resident to dining room. S/he was left unattended in the dining room, breakfast had been served at 8:00 am and the food had been returned to the kitchen at 8:56 am.Staff 2 (consultant/ Interim Executive Director) was alerted to Resident 1 having not received breakfast and being left unattended in the dining room. Staff 2 stated s/he would ensure Resident 1 received breakfast.b. Resident 10's service plan dated 02/20/24 indicated the following:· In Transferring gait belt was listed and Resident 10 was total assistance for transfers. Resident required routine hands-on assistance with transfers and/or changes in position. Resident was to have 2 person staff assistance with transfers by hoyer. Resident was able to stand pivot for transfers from wheelchair to chair in common area. For stand pivot transfers, Resident 10 was to have 2 person staff assistance with use of gait belt.· In Meal consumption Resident 10 required moderate assistance, cutting up food, opening cartons/packages; may have needed encouragement to select menu items. Resident may have needed staff assistance with reminders to eat as sometimes s/he forgot to continue eating during meals. Resident was on mechanical soft diet. General diet, thin liquids, mechanical soft texture. Staff was to assist with appropriate food choices.· A Temporary Service Plan for Resident 10 dated 08/02/23 indicated resident had a diet change to mechanical soft food, with limited distractions and constant reminders to slow down.A review of Resident 10's physician orders dated 11/16/23 did not indicate resident had an order for a modified diet.In an interview on 04/01/24, Staff 6 (Caregiver) and Staff 8 (Caregiver) stated Resident 10 was not on a special diet, and s/he did not like mechanical soft food. Both staff were unsure of what Resident 10's service plan stated for dietary requirements. Staff 8 stated s/he removed the meat from Resident 10's lunch because it was dry and tough and s/he didn't want resident to choke. Both staff stated they always transfered the resident by lifting him/her up by the arms, from his/her wheelchair to his/her bed.In an interview on 04/04/24, Staff 9 (Caregiver) and Staff 10 (Caregiver) stated they stated they usually transfered Resident 10 by grabbing under elbows and doing a stand pivot transfer from bed to wheelchair, because the facility was short staffed and it was faster than the hoyer. Neither staff was sure what the service plan indicated.On 04/01/24 at 12:58 pm Staff 6, Staff 8 and Staff 9 were observed transferring Resident 10 by lifting up on his/her arms, not using a gait belt, from his/her wheelchair to his/her bed.On 04/04/24 at 7:19 am Staff 9 and Staff 10 were observed transferring Resident 10 with a stand pivot transfer and grabbing under his/her elbows from his/her bed to wheelchair. No gait belt or hoyer was used.On 04/01/24 at 12:03 Resident 10 was observed to be served a regular lunch, but with no meat as the other residents were observed to have. Resident was not observed to be offered the alternative taco soup that was available.On 04/04/24 at 8:00 am Resident 10 was served a regular texture meal, but the breakfast sausage was observed to be withheld. No alternative protein was observed to be offered.The facility failed to be responsible for ensuring the implementation of services.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction: Facility leadership was updating service plans continually from move-in date and making updates when due quarterly, to make service plans person centered, and ensured family involvement.

Based on observation and interview, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to 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. Findings include, but are not limited to:In an interview on 05/17/24 Staff 4 (Administrator) stated s/he did not believe the facility has a designated "Infection Control Specialist".On 04/01/24 at 12:43 pm Staff 9 (Caregiver) was observed to pull "clean dishes" off a cart full of dirty dishes and attempt to put them away. Compliance Specialist intervened and provided instruction that once dirty dishes were placed on a cart, for infection control purposes, all other dishes were now dirty.On 04/04/24 after breakfast staff were observed putting dirty dishes on top shelf of rolling carts. The cart had a rack of clean glasses below and staff removed a "clean" glass to pour a new beverage into it for a resident. Compliance Specialist reminded staff that the dishes below were previously clean and this is an infection control problem.On 04/04/24 at 7:19 am a staff members observed transferring and changing a resident. A staff members hair was observed to drag through the residents soiled chuck.The facility failed to 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 findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Verbal Plan of Correction: Inservice meeting on cross contamination was to be held and training packets were provided with infection control practices.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system. Findings include, but are not limited to:On 04/01/24 at 12:58 pm a loose pill was observed in Resident 10's wheelchair. Staff 8 (Caregiver) was alerted to the presence of the medication.Staff 8 asked Compliance Specialist what to do with the medication. Staff 8 was observed to throw the pill in residents trashcan.In an interview on 04/01/24, Staff 11 (RCC) stated when staff find a loose pill s/he should take the medication to the med tech.Resident 10's 04/01/24 - 04/30/24 and progress notes were reviewed on 04/04/24, there were no entries indicating resident did not receive a medication or that a loose pill was found in residents wheelchair.See findings in C0303.The facility administrator failed to be responsible for ensuring adequate professional oversight of the medication and treatment administration system.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.

Based on interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to carry out medication orders as prescribed for 4 of 4 sampled residents (#'s 3, 7, 8, & 9). Findings include, but are not limited to:a. A review of Resident 3's Physician Orders dated 01/01/24 indicated the following:· Methadone 5mg with instructions to " take 0.5 tablet by mouth 2 times daily at 8am and 3pm scheduled for pain", scheduled for 8:00 am and 3:00 pm with an order date 12/29/23;· Quetiapine 50mg with instructions to "take 1 tablet by mouth 2 times daily (morning and at 2pm)", scheduled for 8:00 am and 2:00 pm with an order date 10/06/23; and· Tizanidine 4mg with instructions to "take 2 tablet by mouth every 8 hours every day at 6:00am, 2:00pm, 10:00pm", scheduled for 6:00 am, 2:00 pm and 10:00 pm with an order date 12/26/23.A review of Resident 3's 01/2024 MAR indicated the following:· On 01/01/24 3:00 pm Methadone HCI was marked as not administered;· On 01/01/24 2:00 pm Quetiapine Fumarate was marked as not administered; and· On 01/01/24 2:00 pm and 10:00 pm Tizanidine HCL were both marked as not administered.Resident 3's Chart Notes in 01/2024 MAR indicated the following:· On 01/01/24 3:00 pm Methadone HCI " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ;· On 01/01/24 2:00 pm Quetiapine Fumarate " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ;· On 01/01/24 2:00 pm " INVESTIGATION: MT states that s/he was outside of the hour before/after window therefor did not administer medication " ; and · On 01/01/24 10:00 pm Tizanidine HCL " MEDICATION NOT ADMINISTERED. UNABLE TO CONFIRM WITH AGENCY LPN REASONING "b. A review of Resident 7's 01/2024 MAR indicated the following:· On 01/01/24 5:00 pm Memantine HCI was marked as not administered;· On 01/01/24 5:00 pm Acetaminophen was marked as not administered; and· On 01/01/24 5:00 pm Mirtazapine was marked as not administered.Resident 7's Chart Notes in 01/2024 MAR indicated the following:· On 01/01/24 5:00 pm Memantine HCI "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION";· On 01/01/24 5:00 pm Acetaminophen "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION"; and· On 01/01/24 5:00 pm Mirtazapine "MEDICATION WAS NOT ADMINISTERED: PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ADMINISTER THE MEDICATION".c. A review of Resident 8's physician orders dated 01/01/24 indicated the following:· Levothyroxine 75MCG with instructions to take " 1 tablet by mouth for hypothyroidism " scheduled at 5:00 am with an order date 12/21/23. A review of Resident 8's 01/2024 MAR indicated the following:· On 01/02/24 5:00 am Levothyroxine sodium was marked as not administered.Resident 8's Chart Notes in 01/2024 MAR indicated the following:· On 01/02/24 5:00 am Levothyroxine sodium "MEDICATION NOT ADMINISTERED. UNABLE TO CONFIRM REASONING WITH AGENCY LPN".d. A review of Resident 9's physician orders dated 01/01/24 indicated the following:· Famotidine 20mg with instructions to take "1 tablet by mouth twice daily" scheduled for 8:00 am and 5:00 pm, with an order date 06/23/23.· Melatonin 5mg with instructions to take "1 tablet by mouth every evening" scheduled for 5:00 pm, with an order date 11/28/23.A review of Resident 9's 01/2024 MAR indicated the following:· On 01/01/24 5:00 pm Apixaban was marked as not administered;· On 01/01/24 5:00 pm Donepezil Hydrochloride was marked as not administered;· On 01/01/24 5:00 pm Famotidine was marked as not administered;· On 01/01/24 5:00 pm Melatonin was marked as not administered; and· On 01/01/24 5:00 pm Tamsulosin HCI was marked as not administered.Resident 9's Chart Notes in 01/2024 MAR indicated the following:· On 01/01/24 5:00 pm Apixaban "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";· On 01/01/24 5:00 pm Donepezil Hydrochloride "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";· On 01/01/24 5:00 pm Famotidine "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION";· On 01/01/24 5:00 pm Melatonin "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION"; and· On 01/01/24 5:00 pm Tamsulosin HCI "MEDICATION WAS NOT ADMINSITER; PER MT, S/HE WAS OUTSIDE OF THE HOUR BEFORE/AFTER WINDOW, THEREFORE DID NOT ASMINISTER THE MEDICATION".In an interview on 04/04/24 Staff 4 (Administrator) stated a lot of medication errors had occurred.The facility failed to carry out medication orders as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.Based on interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to carry out medication orders as prescribed for 5 of 5 sampled residents (#'s 2, 8, 11, 12, and 13). Findings include, but are not limited to:A review of Resident 2's March 2024 MAR indicated the following on 03/23/24:· 8:00 am Acetaminophen recorded as "NA";· 12:00 pm Acetaminophen recorded with a dash mark and no initials;· 8:00 am Amlodipine Besylate recorded with a dash mark and no initials;· 12:00 pm Diclofenac Sodium recorded with a dash mark and no initials;· 8:00 am Docusate Sodium recorded as "NA";· 8:00 am Metoprolol Succinate recorded with a dash mark and no initials;· 7:30 am Pantoprazole Sodium recorded as "Med Aide Unavailable";· 8:00 am Blood Pressure was not recorded; and· 8:00 am Pulse was not recordedA review of Facility self-reported missed medication list for Resident 2 on 03/23/24 indicated the following missed medication:· Vitamin B12, Clopidogrel, Folic Acid, Atorvastatin and Vitamin C.A review of Resident 8's March 2024 MAR indicated the following on 03/23/24:· 8:00 am Citalopram Hydrobromide recorded as not given due to "Medication reordered and will be on tonight's delivery";· 8:00 am Lidocaine recorded as "Given late"; and· 9:00 am Daily Weight recorded with a dash mark and no initials.A review of Facility self-reported missed medication list for Resident 8 on 03/23/24 indicated the following missed medication:· Acetaminophen, Cephalexin, Ferrous Sulfate, Citalopram, Lidocaine patch, ergocalciferol, magnesium oxide, memantine, multivitamin, nystatin, pantoprazole, and polyethylene glycol.A review of Resident 11's March 2024 MAR indicated the following on 03/23/24:· 12:00 pm Turmeric Complex 500 mg recorded with a dash mark and no initials.A review of Facility self-reported missed medication list for Resident 11 on 03/23/24 indicated the following missed medication:· Acetaminophen, Amlodipine Besylate, aspirin, calcium carbonate, folic acid, metoprolol tartrate, potassium chloride, prevagen, turmeric and Vitamin B1.A review of Resident 12's March 2024 MAR indicated the following on 03/23/24:· 8:00 am Lidocaine 4% patch recorded with a dash mark and no initials.A review of Facility self-reported missed medication list for Resident 12 on 03/23/24 indicated the following missed medication:· Aspirin, Cholecalciferol, Folic Acid, Lidocaine patch, Magnesium, Metoprolol, Omeprazole, Polyethylene glycol, Vitamin B1, Vitamin B12 and Vitamin D3.A review of facility self-reported medication error dated 03/23/24 indicated the following:· An agency LPN was working as a med tech on 03/23/24;· The LPN did not pass the 8:00 am medications to multiple residents and medications had been pre-popped and mixed with 12:00 pm medications;· At 3:30 pm medications were still waiting to be passed;· Agency LPN came on shift at 9:30 am and RCC oriented agency staff to the charting system and medication room and cart.· At 9:30 am 5 or 6 residents sill needed their medications.In an interview on 04/04/24 Staff 4 (Administrator) stated a lot of medication errors had occured.The facility failed to carry out medication orders as prescribed.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction: A daily clinical meeting was being held every morning to review alert charting, new orders, incidents, missed medications with the nurse, RCC and administrator. Multiple staff trainings had been completed with MT's and Caregivers. The next training to occur was to be focused on a process for found medications.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident. Findings include, but are not limited to:On 04/04/24 the transition from night shift to day shift was observed. At 6:00 am two of four night shift staff left before day shift staff arrived to relieve them. The facility was staffed under the posted staffing plan until approximately 6:20 am.On 04/04/24 at 7:56 am three staff were observed to leave the facility to bring the breakfast meal carts from the kitchen (in the attached Assisted Living Facility). At 8:56 am three staff were observed leaving the facility to bring the food carts back to the kitchen, leaving the memory care staffed below the posted staffing plan.In an interview on 04/04/24, Staff 5 (Caregiver) stated s/he has had to work by him/herself in the recent past with staff from the Assisted living facility assisting.In an interview on 04/04/24 Staff 9 (Caregiver) and Staff 10 (Caregiver) stated they usually transfered Resident 10 by stand pivot because they were short staffed and it was faster than using his/her hoyer.Posted staffing plan was reviewed which indicated:· Day: 1 med tech, 3 caregivers· Swing: 1 med tech, 3 caregivers· Noc: 1 med tech, 2 caregiversA review of 03/01/24 - 03/31/24 schedule indicated both 03/29/24 and 03/30/24 were short staffed per the posted staffing plan.A review of timecards for 03/29/24 and 03/30/24 confirmed the facility was not staffed to the posted staffing plan.The facility failed to provide qualified awake direct care staff sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Facility Verbal Plan of Correction: Facility leadership investigated staff leaving the facility short staff immediately. Administrator will ensure scheduling to staffing plan and ensure coverage on floor until coverage is found. Adminsitrator spoke to care staff and discussed in clinical about not leaving the facility unattended.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed the facility failed to fully implement an Acuity Based Staffing Tool (ABST). Findings include, but are not limited to:In an interview on 04/01/24, Staff 1 (Executive Director), Staff 2 (Consultant/ Interim Executive Director) stated the facility used the Oregon Department of Human Service tool and that Staff 1, Staff 2, and Staff 4 (Administrator) had all been updating the information. Staff 2 stated s/he did not update the ABST last week, but it was updated the Sunday before. A review of the ABST and the resident roster indicated there had been three new admissions, admit dates of 03/22/24, 03/26/24 and 04/01/24, that were not entered into the ABST.The facility failed to fully implement an ABST.The findings of the investigation were reviewed via phone call with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) on 05/17/24.

Based on observation, interview and record review, conducted during a site visit on 04/01/24 and 04/04/24, it was confirmed that the facility failed to verify that direct care staff have demonstrated satisfactory performance in any duty they are assigned for 3 of 3 sampled staff (#'s 5, 6, and 7). Findings include, but are not limited to:Demonstrated competencies were requested for Staff 5, 6 and 7, and no demonstrated competencies were available or provided for 3 of 3 sampled staff.In an interview on 04/04/24, Staff 5 (Caregiver) stated s/he did not recall completing a checklist, signing a checklist or having a trainer sign off on a checklist for training.At 12:58 pm on 04/01/24 three staff members were observed to lift Resident 10 by his/her arms out of his/her wheelchair without the use of a gait belt or other safe techniques and put the resident in his/her bed.In an interview on 04/01/24, Staff 6(Caregiver) and Staff 8 (Caregiver) stated they always transfered the resident the way Compliance Specialist observed.The facility failed to verify direct care staff have demonstrated satisfactory performance in any duty they are assigned.The findings of the investigation were reviewed with and acknowledged by Staff 2 (Consultant), Staff 3 (Regional) and Staff 4 (Administrator) via phone call on 05/17/24.Verbal Plan of Correction: Staff 2 and Staff 4 were to redo all training packets for care staff, gait belt training for all staff had occurred and they were in the process of ensuring all service plans were reflective of needs. Competency checks were to be done and a lead caregiver had been appointed to review for completeness.

The findings of the kitchen inspection, conducted 08/02/22, 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 first revisit, to the kitchen inspection of 08/02/22, conducted on 11/08/22, are documented in this report. The facility was found to be 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, interview and record review, it was determined the facility failed to ensure the kitchen was clean in accordance with the Food Sanitation Rules OAR 333-150-000. Findings include, but are not limited to:1. The kitchen was toured on 08/02/22 at 10:20 am. The following areas were in need of cleaning:*Flooring throughout the kitchen had food crumbs and/or debris;*Flooring inside the walk in refrigerator and freezer had food debris and garbage;*The industrial can opener had black/brown matter in the holding sleeve;*The wall behind the warewasher had dried food/spills;*The shelving under the steam table had black/brown grime;*Dried matter was found on the slicer, blender and robot coupe;*The hood was observed with grease and dust; and*The exit door from the kitchen to the dining room had brown/black matter.2. The kitchenette in the MCC was toured on 08/02/22 at 11:00 am. The following areas were in need of cleaning:*Multiple surfaces on the cupboard doors and handles had dried food matter;*The wall near the refrigerator had dried food matter/splatters; and*Shelving in the kitchenette cupboards used to store non-food items and clean dishes had food crumbs.The areas needing cleaning were discussed with Staff 1 (Executive Director), Staff 2 (Chef) and Staff 3 (Director of Sales and Marketing) on 08/02/22. They acknowledged the findings.

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 240.

The findings of the Change of Ownership survey conducted 3/30/21 through 4/2/21 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 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 daySituations were identified where there was a failure of the facility to comply with the Departments rules that were likely to cause a resident serious harm. Immediate plans of correction to residents' health and safety were requested in the following areas:C160 Reasonable Precautions OAR 411-54-0025 (4)C300 (1) Medication And Treatment Administration Systems. OAR 411-054-0055 (1)aThe facility put immediate plans of correction in place during the survey and the situations were abated.
The findings of the first revisit for the re-licensure survey of 4/2/21, conducted 8/17/21 through 8/18/21 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 OARs 411 Division 004 Home and Community Based Services Regulations.

Based on interview and record review, it was determined the facility failed to maintain complete and accurate records and failed to implement a policy prohibiting the falsification of records for 2 of 4 sampled residents (#s 2 and 3) whose records were reviewed. Findings include, but are not limited to:1. Resident 2 was admitted to the facility 9/2020 with diagnoses including dementia and Parkinson's disease. a. The resident was identified during the acuity interview as being on hospice and bed bound, reliant on staff for all ADL care. Resident 2's service plan instructed staff to provide two supplemental shakes a day, at 10:00 am and 2:00 pm. The resident's March 2021 MAR instructed staff to place a Lidocaine pain patch on the residents lower back every morning at 8:00 am and remove the patch 12 hours later.During an interview on 3/30/21 at 1:44 pm, the residents family members confirmed Resident 2 had not gotten his/her supplemental shake at 10:00 am. On 3/31/21, observations of resident were conducted between 9:19 am and 12:48 pm. Staff did not provide the resident his/her shake at 10:00 am. At 4:20 pm, Staff 2 (RN) confirmed there was no Lidocaine patch on the residents back. On 3/31/21 at 4:30 pm the surveyor requested an updated copy of the resident's March MAR. The 3/30/21 and 3/31/21 10:00 am health shakes had been signed as administered by staff. The 3/31/21 Lidocaine patch was signed as applied at 8:00 am by Staff (11) MA. b. Resident 2 had been identified at risk for weight loss and dehydration. Residents March 2021 MAR instructed staff to "provide Ensure supplement twice daily. Record % consumed". A review of the residents "Intake/Output" log for the month of March 2021 showed staff had not documented on the percentage of intake on any day during the month of March. 2. Resident 3 was admitted to the facility in 2018 with diagnoses including altered mental status, dysphagia (difficulty swallowing), and difficulty walking.On 3/25/21 the resident was placed on meal monitoring. During survey, it was discovered staff were inaccurately documenting meal percentages. (See C270, example 4) The need to ensure resident records were complete, accurate and not falsified was reviewed with Staff 1 (Interim Director of Operations) and Staff 2 on 3/31/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to exercise reasonable precautions against any condition that could threaten the health, safety or welfare of residents. This placed residents at risk and constituted an immediate threat to residents' health and safety. Findings include, but are not limited to:1. During the acuity interview, 3/30/21, Resident's 1, 2 and 4 were identified as needing full meal assistance from care staff. Record review showed Resident 1 had an order for a mechanical soft diet and Resident's 2 and 4 had orders for pureed diets. a. On 3/31/21 at 1:10 pm, Staff 7 (MA) entered Resident 2's room with two bowls of food. One bowl contained mixed vegetables; the other tuna mixed with sauce. The consistency of the food was chunky, not smooth. When asked if the food consistency was considered a puree texture, Staff 7 responded "I don't really know." b. On 4/1/21 at 9:30 am and 12:25 pm Staff 9 (MA) was observed feeding Resident 1 a pureed diet. Staff 9 stated she knew the resident was on a mechanical soft diet, but thought the pureed diet was the only one available. During an interview, 4/1/21 at 3:30 pm, Staff 5 (Dining Services) stated he relied on care staff to tell him which residents needed texture modifications, confirmed he had prepared two puree food items and one mechanical soft plate for breakfast and lunch, and stated staff feeding Resident 1 must have grabbed the wrong bowl. Staff 5 acknowledged the white board hanging in the kitchen which listed residents special dietary needs was incorrect and had not been updated. c. On 3/15/21, staff documented Resident 4 was being placed on alert for "choking" and contacted hospice to request a puree diet. A temporary service plan (TSP) was written the same day notifying staff of the diet change. At the time of survey, the TSP was filed in the resident's medical chart, and not with the service plan available to staff, which stated the resident was on a "regular diet". On 4/1/21 at approximately 4:30 pm the survey team requested an immediate plan of correction to ensure all staff received the correct information regarding the residents specific dietary needs and ensure all residents were receiving the correct textured diets. At 5:00 pm, the surveyor observed two agency staff members serving residents their dinner meal. One agency staff stated this was her first night working on the memory care, and proceeded to pull a foil covered bowl from the hot cart, at which point the other agency staff stated "that is for our feeders". There was no marking on the foil indicating which resident the meal was for or what the texture of the food was. At 5:44 pm a plan was received and accepted by the survey team and the immediate jeopardy was abated. 2. Resident 2 was admitted to the facility 9/2021 with diagnoses including dementia.On 3/31/21, the surveyor obtained permission and observed two CGs provide incontinent care to Resident 2, who was bed bound. During the observation, Staff 7 (MA) and Staff 11 (MA) failed to change gloves after removing Resident 2's soiled incontinent brief. Staff 11 placed the soiled brief directly on the resident's floor. Staff then cleansed the resident's perineal area, put a clean brief on the resident, adjusted pillows and bed sheets, then handed the resident a small stuffed animal to hold and picked up the soiled brief and placed it in a plastic bag. Staff 7 and 11 then left the residents room without removing their soiled gloves or performing hand hygiene. 3. Resident 1 was admitted to the facility 12/2019 with diagnoses including dementia. On 3/31/21, the surveyor obtained permission and observed three CGs provide incontinent care to Resident 1, who was bed bound. At 12:37 pm, Staff 7 (MA), Staff 11 (MA) and Staff 13 (CG) entered Resident 1's room to change his/her brief and pad. All three staff put on gloves prior to entering the room. During the observation, Staff 13 removed the residents soiled brief and tossed the brief and pad onto the floor. Staff 13 then cleaned the residents backside, and with the same gloves placed a clean brief and pad under the resident. The other two staff assisted with turning and repositioning of the resident. Staff 13 picked up the soiled brief and placed it in a plastic bag. All three staff removed their gloves before exiting the residents room; however, there were no observations of the staff performing any type of hand hygiene. The need to ensure staff consistently used effective universal precautions was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 3/31/21. They acknowledged the findings. 4. Refer to survey citations:C270 Change of Condition and Monitoring;C280 Resident Health Services - Significant Change; andC300 Systems: Medications and Treatments.

Based on interview and record review, it was determined the facility failed to promptly investigate injuries of unknown cause to rule-out abuse, and failed to document all required areas of an investigation for 2 of 3 sampled residents (#s 2 and 4) with injuries of unknown cause. Findings include, but are not limited to:1. Resident 2 was admitted to the facility 9/2020 with diagnoses including dementia and Parkinson's disease. * On 2/11/21 staff documented the resident had an unwitnessed fall on the night shift. Staff identified a "quarter sized blue and purple bruise" on the left side of the resident's forehead. * On 2/17/21 Staff 2 (RN) described the incident in the residents charting notes, and ruled out abuse stating, "service plan was being followed at the time of the fall." There was no documented evidence of an investigation prior to the note written by the RN on 2/17/21, and no documentation the administrator had reviewed the incident. 2. Resident 4 admitted to the facility 11/2018 with diagnoses including dementia and depression. * On 1/27/21 Staff 3 (LPN) summarized a skin observation note written by a care staff on 1/23/21 who had identified a "skin tear" on the left side of resident's buttock while showering the resident. * A temporary service plan, dated 1/29/21, noted "on coccyx shear from moisture" "apply barrier cream with every toileting". * On 4/1/21, Staff 2 (RN) stated resident had "shearing" on his/her buttock due to moisture and an incontinent pad, but the injury was "not a skin tear". There was no documented evidence the facility had conducted an immediate investigation of the injury to include the time, date, description of the event, response of staff at the time of the event, follow up action, or administrator review. There was no evidence the facility had ruled out abuse. The need ensure injuries of unknown cause or incidents of abuse or suspected abuse were immediately investigated, contained all required areas of documentation, including administrator review, was discussed with Staff 1 (Interim Director of Operations) and Staff 2 on 4/2/21. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the kitchen was clean and in good repair in accordance with Food Sanitation Rules, OAR 333-150-000. Findings include, but are not limited to:During the kitchen tour with Staff 5 (Dining Services) on 3/30/21 at 10:12 am, the following areas were observed to need cleaning or repair:Food spills, splatters, debris, dirt, and black matter was observed on or underneath the following:Main Kitchen 1st Floor:* Floors throughout the kitchen and in the freezer had black matter build-up and food debris;* Walls throughout the kitchen;* Doors;* Small fridge by exit door;* Microwave exterior and interior;* Metal racks in food storage;* Stove front, knobs, top and the sides;* Fryer top, sides and front;* Wall above dish washer and under sink; and* Wall above hand washing sink.MCC Kitchenette 2nd Floor:* Ceiling light panel.The following areas needed repair:Main Kitchen 1st floor:* Light panel above dishwasher was missing;* Prep table cutting board was stained and discolored;* Cabinetry was chipped;* Tile under stove was broke and missing; and* Service bar outside of the kitchen had chipped countertop corner and edges.MCC Kitchenette 2nd Floor:* Shredded chipped edge along both sides of cabinets above sink;* Door to kitchenette was unlocked and broken;* Garbage can was uncovered; and* Side table in dining room was chipped and detached along top edge.In an interview on 3/30/21, Staff 5 stated he needed to hire more staff. He showed the surveyor a wall with clipboards and stated he had papers outlining kitchen cleaning duties for each staff that would be posted. At 11:00 am, the surveyors and Staff 1 (Interim Director of Operations) toured the kitchen. Staff 1 acknowledged the above areas that needed to be cleaned or repaired.

2. Resident 1 was admitted to the facility in 12/2020 with diagnoses including dementia.Observations, staff and family interviews, and record review during the survey identified Resident 1 was bed bound, incontinent of bowel and bladder, required 2-3 people for transfers, had a wound to the right hand, was receiving hospice services and was dependent on staff for all ADL care including feeding assistance. Resident 1's service plan, dated 12/29/21, noted staff would need to ask the resident if s/he needed to use the toilet every 2-3 hours while awake and to perform frequent checks every two hours to ensure safety. A temporary service plan (TSP) dated 3/13/21 instructed staff to do frequent checks, ensure his/her fingers were wrapped, assist with feeding and report changes to MA and RN. In an interview, 3/31/21, Staff 11 (MA) stated the resident was checked every hour to two hours to ensure the bandage on the right hand was in place and to reposition the resident. During observations on 3/31/21 from approximately 9:30 am to 2:40 pm no staff were observed entering the residents room to check on him/her, provide incontinent care or reposition the resident.In a telephone interview, 3/31/21, Resident 1's family member indicated when s/he visits, the resident has been found lying in the same position, with the same unchanged sheets from days prior, dried food debris was present on the resident and in the bed, and s/he was wearing the same unlaundered shirt and his/her room was unkept. S/he conveyed there was a lack of monitoring and interventions for residents' overall care and safety. In an interview, 4/1/21, Resident 1's hospice RN stated she was concerned the resident was not being repositioned. She had just completed assessing the resident, and reported when she entered the residents room the bandage on the right hand was off and a new blister had formed on the side of the hand, new areas of excoriated skin were present on his/her hips and backside, and a deep tissue injury had developed on the right heel. On 4/1/21, at 9:45 am two caregivers were observed walking into Resident 1's room. Staff 13 (CG) started to feed the resident breakfast. Resident 1 only took a few bites, drank the 6 oz juice and 200 ml of water. After breakfast, Resident 1 was observed lying in the same position until 1:30 pm. The need to ensure the facility consistently provided assistance with ADL's as service planned was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/2/21. They acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to consistently provide assistance with ADL's for 2 of 4 sampled residents (#s 1 and 2) who required full ADL assistance for all cares. Resident 1 and 2's lack of ADL care placed the residents at risk for harm. Findings include, but are not limited to:1. Resident 2 was admitted to the facility 9/2020 with diagnoses including dementia and Parkinson's disease. Resident 2 was identified during the acuity interview as newly admitted to hospice services and dependent on staff for all ADL care. Observations of the resident during the survey revealed s/he was dependent on staff for ADL cares, was not able to feed or hydrate him/herself independently and did not advocate for him/herself. The service plan, dated 1/14/21, and temporary service plans dated 3/9/21 and 3/10/21 instructed staff to offer fluids, provide frequent checks, reposition frequently, and provide assistance with hygiene. During a family interview on 3/30/21 at 1:44 pm, the residents family member stated s/he had brought in a new toothbrush and toothpaste "nine days ago" so staff could provide oral care, but the packages for the toothpaste and toothbrush had not been opened. The surveyor observed the packaged toothpaste and toothbrush on a side table in the resident's bathroom during the interview, and on 3/31, 4/1 and 4/2/21. The toothbrush had not been removed from the package. On 3/31/21, no fluids were offered to Resident 2 between 8:19 am and 1:30 pm. Staff also did not provide resident with an ordered health shake at 10:00 am. On 4/1/21 Staff 2 (RN) stated hospice was supposed to bring in mouth swabs and an oral rinse but had not done so yet. On 4/1/21 at 1:10 pm Staff 11 (MA) brought a lunch tray into the resident's room and attempted to feed the resident. The surveyor asked if resident was usually offered fluids during lunch, Staff 11 stated "yes", "I just forgot". Staff 11 offered bites of food to the resident, but s/he refused. No fluids were offered during the observation. Failure to ensure Resident 4 was assisted with hydration, received oral care and nutritional supplements as ordered was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) 4/2/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure quarterly evaluations were accurate for 1 of 4 sampled residents (#3) whose evaluations were reviewed. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2018 with diagnoses including altered mental status, dysphasia (difficulty swallowing), and difficulty walking.The quarterly evaluation dated 1/19/21 for Resident 3 lacked information that Resident 3 had an unexplained weight loss of 7.5% of his/her body weight on 12/15/20. The evaluation was not reflective and therefore was not an accurate foundation to develop the resident's service plan in the areas of weight loss and meal assistance.The need to ensure evaluations were accurate was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN). No further information was provided.

2. Resident 3 was admitted to the facility in 2018 with diagnoses including altered mental status, dysphagia (difficulty swallowing), and difficulty walking.Review of Resident 3's record revealed an unplanned weight loss of 7.5% of his/her body weight noted on 12/15/20.Resident 3's 1/21/21 service plan indicated there had been no recent weight loss, and that Resident 3 was not at risk for weight loss.Resident 3's 1/21/21 service plan was not reflective and lacked clear direction to staff in the area of weight loss and meal assistance.The need to ensure service plans were reflective of resident needs and included clear direction to staff was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN). 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 status and care needs, were updated and readily available for staff, provided clear directions regarding delivery of services and were followed by staff for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include but are not limited to: 1. Resident 1's service plan dated 12/29/20 and available to staff was not reflective of the resident's current status and care needs, or lacked specific instruction to staff in the following areas:* Customary routines as it relates to sleeping and eating; * Cultural preferences; * Visits to the ER and hospital in the past year; * Diet texture and consistency of fluids; * Hydration needs and snacks;* Nutrition supplements; * Joint contractures;* Care refusals and interventions;* Increased aggressive behaviors toward staff; * Dressing, grooming, personal hygiene and oral care status;* Incontinent care provided in bed;* Potential for skin breakdown; * Edema;* Weights and the risk for weight loss;* Environmental factors that impacted the resident's behavior including, noise, lighting and room temperature; and* Recent losses.Observations conducted during the survey indicated Resident 1's service plan was not followed by staff in the areas listed below: * Diet texture;* Repositioning and incontinent care; and* Snacks and liquids between meals.Resident 1's service plan had been updated on 3/24/21; however, the facility failed to ensure the updated service plan was readily available for staff to review. The need to ensure service plans were reflective of residents' current care needs, were updated and readily available for staff, provided clear directions regarding delivery of services and were followed by staff was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.
3. Resident 2 was admitted 9/2020 with diagnoses including dementia and Parkinson's disease. A review of Resident 2's service plan, dated 1/14/2021, and made available to staff, was not reflective of residents current care needs or lacked specific instruction to staff in the following areas:* Bed bound status;* Two person assist with transfers, brief changes and dressing;* Bed baths;* Recent hospital stay;* Signs and symptoms of anxiety;* Puree diet;* Evacuation assistance by two staff members;* Ambulation status; * Hospice services;* Skin condition including recent skin breakdown; * Weight loss; and * Meal assistance. Observations conducted during the survey indicated Resident 2's service plan was not followed by staff in the areas listed below: * Floating heals;* Supplemental shakes;* Oral care;* Bathing assistance; and* Providing fluids. The need to ensure resident service plans were accurate, updated with changes, provided clear direction to staff on the delivery of services, and were followed was reviewed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/2/21. They acknowledged the findings. 4. Resident 4 admitted to the facility 11/2018 with diagnoses including dementia and depression.A review of Resident 4's service plan, dated 1/19/2021, and made available to staff, was not reflective of the residents current care needs or lacked specific instruction to staff in the following areas:* Thickened liquids;* Bed baths;* Weight loss interventions;* Behaviors and interventions; and* Air flow mattress. The need to ensure resident service plans were accurate, updated with changes, and provided clear direction to staff on the delivery of services was reviewed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/2/21. 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 included the resident, the resident's legal representative if applicable, any person of the resident's choice, the Administrator or designee, and at least one other staff person who was familiar with or who was going to provide services to the resident for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Service plans for 4 of 4 sampled residents reviewed did not show evidence that 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 Director of Operations) and Staff 2 (RN). They acknowledged the findings.

4. Resident 3 was admitted to the facility in 2018 with diagnoses including altered mental status, dysphagia (difficulty swallowing), and difficulty walking.Review of Resident 3's MAR indicated Staff 2 (RN) initiated the intervention of meal monitoring on 3/25/21. Review of the MAR showed the MA initials on the MAR each day, however, the amount of food eaten was not documented on the MAR. In interview on 3/30/21, Staff 2 stated there was a separate report that showed the amount of food consumed, the "intake/output" log. Review of the "intake/output" log showed the percentage of meals eaten for 3/30/21 documented "10:00 am meal 0%", and "1:30 pm meal 50%".In interviews on 3/30/21, it was revealed the MAs who initialed the meal monitoring on the MAR did not observe how much the residents ate, but relied on caregivers to report an estimate of how much they ate.Observation at 2:00 pm on 3/30/21 showed Resident 3 seated with the lunch meal uneaten beside him/her. Resident 3 stated s/he did not eat any of the meal.Staff 2 was brought to the room at 2:10 pm, confirmed the meal had not been eaten, and confirmed it should not have been documented as 50% eaten. Staff 2 acknowledged the meal monitoring on the MAR and the input/output log had not accurately recorded Resident 3's food intake.The need to accurately monitor interventions and their effectiveness was discussed with Staff 2 and Staff 1 (Interim Director of Operations), they acknowledged the findings.
Based on observation, interview and record review, it was determined the facility failed to ensure residents who experienced changes of condition were evaluated, resident-specific actions or interventions were developed and communicated to staff, and the conditions were monitored to resolution, and residents who had a significant change of condition were referred to the RN for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose records were reviewed. Resident 1 experienced a worsening of a wound on his/her right hand that later became infected. Findings include, but are not limited to:Resident 1 was admitted to the facility in 2019 with diagnoses including dementia. Resident 1's charting notes dated 12/31/20 to 3/29/21 were reviewed and identified the following: a. On 1/9/21 staff documented the resident had increased bilateral leg edema. No further information concerning the edema was documented including monitoring to resolution. b. On 2/25/21 Staff 6 (MA) documented the resident had a skin tear on the right side of his/her middle finger and was placed on alert charting. Staff did not document the size or appearance of the wound. * A temporary service plan (TSP) dated 2/25/21 instructed the MA's to provide basic wound care as needed and for staff to monitor for bleeding and odor.* Staff documented the resident refused wound care on 2/26/21, 2/27/21, 2/28/21 and 3/1/21. * On 3/2/21 Staff 3 (LPN) documented "no signs of an infection" she further documented "a few fingers were calloused" and the resident was picking at the skin on his/her fingers. No monitoring instructions or interventions were developed to address the resident picking at his/her fingers. * On 3/4/21 Staff 3 documented "fingers remain the same and have not worsened" noted she would continue to monitor weekly. Staff 3 wrote a TSP instructing staff to apply lotion or cream to resident's hands for moisture. * There was no evidence the facility monitored the wound between 3/4/21 and 3/12/21.* On 3/12/21 Staff 3 noted "resident fingers remain the same" and she had observed the resident biting the tips of his/her fingers. * On 3/13/21 Resident 1 was placed on alert for "finger chewing" on his/her finger causing the finger to bleed. Staff 3 documented "Finger swollen and misshapen." A TSP dated the same day instructed staff to do frequent checks on the resident, assist with feeding, ensure finger was wrapped and "report changes to MT and RN." There was no evidence interventions had been developed or monitoring instruction had been given to staff with regards to the resident chewing his/her fingers. * On 3/15/21 Staff 2 (RN) wrote a "follow up note" which stated "the resident has been chewing on his/her fingers which explains recent blood blisters on tips of fingers". There was no further documentation by the RN regarding the wound.* On 3/17/21 Hospice RN performed wound care and ordered antibiotics for the infected finger. * On 3/18/21 a TSP indicated wound care would be done by the Hospice or facility RN.* On 3/20/21 Staff 6 (MA) noted resident's "right middle fingernail was hanging off." * 3/24/21- Staff 2 documented a "significant change of condition" related the residents inability to participate in ADL's, noted the resident was bed bound and had been biting his/her fingers. No description of the wound was documented in the RN's note, no monitoring instructions or interventions to help prevent the resident from biting his/her fingers were provided to staff. There was no evidence residents service plan had been updated with the changes. In an interview, 4/1/21 at 8:51 am, Resident 1's Hospice wound care RN stated the resident had chewed on his/her right middle finger "all the way down to the muscle" and had subsequently developed an infection requiring an antibiotic. The failure of the facility to evaluate, develop resident-specific actions or interventions and monitor conditions to resolution was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/2/21. They acknowledged the findings.
2. Resident 2 was admitted to the facility 9/2020 with diagnoses including dementia and Parkinson's disease. A review of the resident's clinical record and chart notes indicated the following:a. On 2/28/21 Staff documented " ...on alert for open area/skin tear under right side buttock". On 3/2/21 Staff 3 (LPN) described the area as a "pressure injury", measuring 5x5 centimeters and .05 in depth. There was no evidence the facility had referred the pressure sore to the RN for a significant change of condition assessment. b. On 3/9/21 and 3/10/21 staff documented resident 2 was "extra drowsy and slightly pale during noon mealtime", "lethargic and not wanting to eat lunch". On 3/10/21 resident was sent to the emergency department and returned the same day. Resident was diagnosed with a urinary tract infection and "slight pneumonia" and was started on antibiotics. * A temporary service plan dated 3/10/21 instructed staff to "encourage fluids frequently, reposition resident in bed and in wheelchair often" report any changes to MA and RN. * Between 3/11/21 and 3/17/21 staff documented multiple times resident was refusing to get out of bed, refusing meals, and needing full assistance with all ADL cares. Resident was sent to the hospital on 3/17/21 for "gurgling and not being able to look directly at someone". S/he returned to the facility 3/20/21 with diagnoses related to malnutrition and dehydration. S/he readmitted to the facility on hospice. There was no documented evidence the facility had completed a thorough evaluation of the resident, updated the service plan to reflect all areas of the residents significant decline in ADL abilities, determined specific actions or interventions related to the resident's inability to feed or hydrate him/herself, or had accurately and consistently monitored food and liquid intake. The facilities failure to have a system in place to monitor, evaluate, develop actions or interventions and communicate those actions and interventions to staff, and the failure to report a residents significant change of condition to the RN for assessment was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/1/21. They acknowledged the findings. No further information was provided. 3. Resident 4 was admitted to the facility 11/2018 with diagnoses including dementia and depression.A review of Resident 4's clinical record and chart notes indicated the following: a. Between October 2020 and March 2021 Resident 4 experienced a significant weight loss of 8.96% of his/her total body weight, or 12.8 lbs. over a six-month period. The following monthly weights were recorded in the resident's chart: * 10/13/20 - 142.8 lbs.; * 11/6/20 - 142.8 lbs.;* 12/14/20 - 140.8 lbs.;* 1/5/21 - 132.4 lbs.; and* 3/1/21 - 130 lbs; * No weight was recorded in February 2021.There was no documented evidence the facility had evaluated the residents weight loss, monitored for further weight loss, evaluated interventions for effectiveness, or referred to the RN for a significant change of condition. b. On 2/2/21 hospice reported resident was "combative with staff and resisting am care". On 2/6/21 the resident started an 8:00 am dose of routine Lorazepam (anti-anxiety medication). A temporary service plan was written the same day directing staff to monitor for "dizziness, diarrhea, dry mouth or drowsiness". There was no documentation in the residents record of combativeness or resisting care prior to the 2/2/21 hospice note. There was no evidence the facility monitored the effectiveness of the Lorazepam with regards to resident's behaviors. c. On 1/27/21 Staff 3 (LPN) summarized a skin observation note written by a care staff on 1/23/21 who had identified a "skin tear" on the left side of resident's buttock. There was no evidence the facility had evaluated the skin or monitored the injury to resolution. d. On 2/4/21 Staff 3 documented in the resident chart notes a wound on the resident's coccyx "has now opened up and is a pressure injury". There was no evidence the facility consistently monitored the wound or referred to the facility RN for a significant change of condition. e. On 2/19/21 Staff 3 documented "diet was changed to soft food and thickened liquids". There was no evidence the facility monitored how the resident responded to the texture modifications. f. On 3/15/21 the resident was placed on alert charting for "choking". "Staff was assisting feeding and resident went blue in face and lips." "This MT went to room and performed CPR, resident started to breath and got color back". Staff then requested a puree diet be ordered from hospice. There was no follow up documentation or monitoring addressing the possible use of "CPR" on the resident. g. Resident 4 was prescribed routine senna (stool softener) on 3/22/21. There was no documented evidence the facility had monitored for the effectiveness of the medication. h. On 3/26/21 the resident was identified as having a "new skin breakdown observed on coccyx." There was no follow up documentation or monitoring of the skin issue. The facilities failure to have a system in place to monitor, evaluate, develop actions or interventions and communicate those actions and interventions to staff, and the failure to report a residents significant change of condition to the RN for assessment was discussed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/1/21. They acknowledged the findings. No further information was provided.

4. Resident 3's record was reviewed during survey and indicated the resident had experienced a severe weight loss of 7.5% of his/her total body weight, or 8.6 lbs between 11/1/2020 and 12/14/21. This constituted a significant change of condition.There was no documented evidence the RN had assessed the resident's weight loss or developed interventions made as a result of the assessment. The lack of an RN assessment regarding Resident 3's significant change of condition was reviewed with Staff 1 (Interim Director of Operations) and Staff 2 (RN). They acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure a significant change of condition assessment was completed by the RN, to include findings, resident status and interventions, for 4 of 4 sampled residents (#s 1, 2, 3, and 4) who experienced significant changes of condition. Resident 1's skin wound developed into an infection. Findings include, but are not limited to:1. Resident 1 was admitted to the facility in 2019 with diagnoses including dementia. Resident 1's records were reviewed during survey and identified the following:Charting notes dated 2/25/21 thru 3/29/21, identified Resident 1 experienced a significant change of condition related to a self-inflicted injury of biting and chewing on his/her right middle finger, resulting in a wound. In an interview on 4/1/21 at 8:51 am, Resident 1's Hospice RN reported the resident had chewed on his/her right middle finger "all the way down to the muscle" and had subsequently developed an infection requiring antibiotics. Hospice had been providing routine wound care on the finger. There was no documented evidence the RN completed a significant change of condition assessment for the wound on the residents finger, to include findings, resident status, and interventions made as a result of the assessment. The lack of an RN assessment regarding the resident's ongoing biting of his/her fingers resulted in a wound and subsequently developed into an infection.The lack of an RN assessment regarding Resident 1's significant change of condition was reviewed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings. Refer to C270, example 1.
2. Resident 2 admitted to the facility 9/2020 with diagnoses including dementia and Parkinson's disease.A review of the resident's clinical record and chart notes showed the following: a. On 3/2/21 Staff 3 (LPN) noted a pressure injury on the resident's right buttock measuring 5x5 centimeters and .05 in depth. This constituted a significant change of condition. There was no evidence the facility RN had completed a significant change of condition assessment on the pressure wound, to include documented findings, resident status, and interventions made as a result of the assessment. b. Between 3/9/21 and 3/17/21 Resident 1 became bed bound, refused and was unable to feed him/her self or hydrate independently, became fully dependent on all ADL care from staff and subsequently was admitted to hospice on 3/20/21. This constituted a significant change of condition. Staff 2 (RN) wrote a "significant change of condition" chart note on 3/21/21, which included the statement "no changes made to [his/her] service plan as the service plan was changed prior to [him/her] going on hospice". On 3/10/21 a temporary service plan instructed staff to "encourage fluids frequently, reposition resident in bed and in wheelchair often". There was no other documented evidence the licensed nurse had participated or reviewed the residents service plan for accuracy or updates within 48 hours of the resident's significant change of condition and admission to hospice. The service plan available to staff at the time of survey was dated 1/14/21.The lack of an RN assessment and failure to update the service plan within 48 hours of a residents change of condition was reviewed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings. 3. Resident 4 was admitted to the facility 11/2018 with diagnoses including dementia and depression.A review of resident's clinical record and chart notes showed Resident 4 had experienced a significant change of condition on two separate occasions. a. Between October 2020 and March 2021 Resident 4 experienced a significant weight loss of 8.96% of his/her total body weight, or 12.8 lbs. over a six-month period. b. On 2/4/21 Staff 3 documented in resident chart notes a wound on resident's coccyx "has now opened up and is a pressure injury". There was no evidence the facility RN had completed a significant change of condition assessment for the weight loss or pressure sore, to include documented findings, resident status, and interventions made as a result of the assessment.On 4/2/21 the need to ensure the facility RN completed an assessment for all residents who experienced a significant change of condition was discussed with Staff 1 (Interim Director of Operations). She acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure a safe medication and treatment system was in place and failed to ensure adequate professional oversight of the medication and treatment administration systems. Findings include, but are not limited to:1. During the survey, conducted 3/30/21 through 4/2/21, the survey team identified the following concerns:On 4/1/21 at approximately 10:00 am, Staff 2 (RN) was observed conducting the morning medication pass. When interviewed, Staff 2 stated the caregiver scheduled to work the day shift had "read the schedule wrong" and had not shown up, so she asked Staff (9) MA to work as a caregiver while Staff 1 passed medications. During a follow up interview, 4/1/21 at 10:10 am, Staff 9 stated she had been scheduled to work as a med aide "today" but was not aware prior to starting her shift she would be working alone. Staff 9 had only worked one shift as a med aide on the memory care on 3/26/21, and confirmed she was not comfortable passing medication with only one day of training. At 10:24 am, the surveyor requested the April 2021 staff schedule from Staff 1 (Interim Director of Operations). Staff 1 provided the schedule and stated she was not aware Staff 9 had not completed medication training prior to scheduling her to work independently. Staff 2 stated during the interview that Staff 3 (LPN) was responsible to sign off on med aide competencies, and each new med aide received a minimum three days training with Staff 3 or another med aide before working independently. The survey team reviewed the April 2021 schedule which showed Staff 10 (CG), hire date 3/21/21, was scheduled to work the evening and night shifts as a med aide on 4/2/21 and also train a new med aide on the evening shift that same day. The facility was unable to provide documentation Staff 10 had demonstrated competency in order to perform safe medication and treatment administration unsupervised.At 2:40 pm, the surveyor requested copies of demonstrated competencies and training for all staff assigned to administer medications in the memory care. The facility was unable to provide documented evidence observations and evaluations had been completed to determine staff's ability to perform safe medication and treatment administration unsupervised for the following staff: Staff 7 (MA), hired on 3/24/21; Staff 8 (MA), hired on 6/12/20; Staff 9 (MA), hired 3/26/21; Staff 10 (MA/CG), hired 3/21/21; andStaff 12 (MA), hired on 5/12/20. On 4/1/21 at 3:00 pm the survey team requested an immediate plan of correction to address the lack of competency training for Staff 7, 8, 9, 10 and 12. At 4:14 pm a plan was received and accepted by the survey team and the immediate jeopardy was abated.2. Administrative oversight of the medication and treatment administration system was also found to be ineffective, based on deficiencies in the following areas:C 303: Systems: Medication and Treatment Orders; andC 310: Systems: Medication Administration; andThe unsafe medication system and lack of adequate professional oversight was discussed with Staff 1 and Staff 2 on 4/1/21. They acknowledged the findings.

2. Resident 1 moved into the facility in December of 2019, with diagnoses including dementia. Current physician orders and the March 1st through 30th 2021 MAR for Resident 1 were reviewed and the following was noted:a. On 3/5/21, 3/8/21, 3/9/21 and 3/10/21 staff administered a PRN dose of Morphine ( medication to be administered for pain or dyspnea) and documented on the resident's MAR the reason given was for "Incontinent Care"; b. On 3/5/21, 3/9/21 and 3/10/21 staff administered a PRN dose of Lorazepam (medication to be administered for restlessness or agitation) and documented on the resident's MAR the reason given was for "Incontinent Care"; and c. On 3/8/21 staff administered a PRN dose of Tylenol ( medication to be administered for for fever or mild pain) documented on the resident's MAR the reason given was "to ease behaviors while [s/he] is changed". The need to ensure medications were administered as ordered was reviewed Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure medication and treatment orders were carried out as prescribed, for 2 of 4 sampled residents (#s 1 and 2) whose orders were reviewed. Findings include, but are not limited to:1. Resident 2's physician orders, dated 3/20/21, and 3/1/21 through 3/30/21 MARs were reviewed during the survey. The following prescribed medications had not been transcribed to the residents March 2021 MAR, therefore were not administered as ordered:* PRN Bisacodyl suppository (for constipation);* Fexofenadine 180 mg. (allergy medication);* Melatonin 1 gm (sleep aid); and * PRN Mirilax powder (for constipation).The facility's failure to follow physician orders as prescribed was reviewed with Staff 1 (Interim Director of Operations) and Staff 2 (RN) on 4/1/21 and 4/2/21. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included reason for use and resident-specific parameters for PRN medications for 3 of 4 sampled residents (#s 1, 2 and 4) whose medications were reviewed. Findings include, but are not limited to: 1. Resident 2's 3/1/21 through 3/30/21 MAR was reviewed during the survey. The following medications lacked a reason for use: * Routine Acetaminophen 500 mg for pain;* Bion Tears eye drops; and * Cephalexin antibiotic. The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings2. Resident 4's 3/1/21 through 3/30/21 MAR was reviewed during survey. The following medications lacked a reason for use:* Hydrocodone/APAP for pain; and* Both the routine dose and PRN dose of Lorazepam (for anxiety). The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.
3. Resident 1's 3/1/21 through 3/30/21 MAR was reviewed and identified the following medications were lacking a reason for use: * Amoxicillin/Clavulanate; and* Scheduled Morphine. The need to ensure MARs were accurate and included reasons for use was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 newly hired staff (#s 7, 8, 9, 10 and 12) had documented demonstration of competency in First Aide and abdominal thrust within 30 days of hire or prior to providing resident care independently and administering medications unsupervised. Findings include, but are not limited to:Staff 7 (MA), hired on 3/24/21; Staff 8 (MA), hired on 6/12/20; Staff 9 (MA), hired 3/26/21; Staff 10 (MA/CG), hired 3/21/21; and Staff 12 (MA), hired on 5/12/20 lacked evidence they had completed First Aid and abdominal thrust for choking. The need for the facility to ensure it had systems for documenting required staff competency demonstrated within 30-days of hire, or prior to independently performing the duties, including completion of First Aid and abdominal thrust, was discussed with Staff 1 (Interim Director of Operations), Staff 2 (RN), and Staff 4 (Business Office Manager) during the survey. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure fire drills were conducted and recorded in accordance with the Oregon Fire Code (OFC) and fire and life safety instruction was provided on alternate months. Findings include, but are not limited to: On 3/30/21, fire drill and fire and life safety training records for the previous six months were requested for review. No records were provided to review; therefore, there was no documented evidence the facility was conducting fire drills every other month in accordance to the OFC and no documented evidence fire and life safety instruction was provided to staff on the alternating months. In an interview on 3/30/21, at 4pm, Staff 1 (Interim Director of Operations)acknowledged the facility was not conducting fire drills every other month and not providing fire and life safety instruction on alternate months. Staff 1 reported, she had recently contacted their local fire marshal and would be conducting two fire drills by the end of the month. No additional information was provided.

Based on interview and record review, it was determined the facility failed to ensure general fire and life safety requirements were being met. Findings include, but are not limited to:On 3/30/21, the facility's fire and life safety records were requested for review.No records were provided to review; therefore, there was no documented evidence of the following general fire and life safety requirements: * Evidence alternative exit routes were used during fire drills; * Evidence staff and residents participated in fire drills and training to assess ongoing evacuation capabilities of both residents and staff; and* Documentation of interventions and resolution related to resident evacuation concerns identified during fire drills.The need to ensure all general fire and life safety requirements were implemented and followed was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the environment was clean and maintained in good repair. Findings include, but are not limited to:Observations of the facility on 3/30/21 through 4/2/21 showed the following areas were in need of cleaning and/or repair:* Multiple hand rails throughout the unit had chipped paint and gouges exposing wood;* Two fire extinguisher wall casing doors were pried open and bent;* Bathroom door to rooms 210A and 210B was off the hinges and leaning against the wall next to the bathroom entrance;* Furniture in the common area near the medication room was stained with blue and brown smudges; * Exit sign near the memory care satellite kitchen was hanging from the ceiling with exposed wires;* Secured courtyard was scattered with paper cups and other debris, evidence cigarettes had been extinguished on the pavement leaving black smudges and ashes in the corner near courtyard gate, patio tools and ceramic figurines were left out or tipped over, cobwebs around the patio door, light fixture and windows; * The roof of the elevator to the memory care was missing plastic ceiling panels, showing exposed electrical equipment;* The bottom of the stairway on the first floor had an electrical cord which was plugged in and ran across the path to the stairway causing a tripping hazard. A ladder and chemicals were stored in the same area directly at the bottom of the stairs; and* Ceiling tiles adjacent to room 210A and 210B were stained with large brown and black areas that looked like it resulted from water leaks. The need to ensure the environment was kept clean and in good repair was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure the door that exited to the interior courtyard was equipped with an operational alarming device or other acceptable systems to alert staff when residents exited into the courtyard, and failed to provide a call system that connected resident units to the care staff or staff pagers on the memory care unit. Findings include, but are not limited to:A tour of the facility, 3/30/21 revealed the following: 1. There was no exit door alarm to the secured patio area that would alert staff when the doors were opened.On 3/31/21 Staff 1 (Interim Director of Operations) acknowledged there was no alarm on the door exiting to the patio and stated she would order an alarm that day; and 2. Staff on the MCC did not carry pagers that connected to the call system in place on the unit. During an interview on 3/30/21 at 2:15 pm, Staff 11 (MA) confirmed memory care staff did not carry pagers. On 3/31/21 Staff 1 stated she had contacted the call system company and activated pagers for the staff on memory care, at which time she passed out pagers to two staff members on memory care. The need to ensure exit doors were equipped with an alarming device to alert staff when residents entered the courtyard, and to ensure a call system was in place which connected resident units to the memory care staff was discussed with Staff 1 on 3/30/21 and 3/31/21. She 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 Change of Ownership licensing survey, conducted 3/30/21 through 4/2/21, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the citations issued during the survey. Refer to deficiencies in report.

Based on interview and record review, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. Findings include, but are not limited to:Refer to C155, C160, C231, C240, C243, C372, C420, C422, C513, C555.

Based on interview and record review, it was determined the facility failed to ensure 5 of 5 newly hired staff (#s 7, 8, 9, 10, 12 and 13) had documented demonstration of competency in all areas within 30 days of hire or prior to providing resident care independently and administering medications unsupervised; and that annual training was completed and documented for 1 of 2 long term staff (#13). Findings include, but are not limited to:1. Staff 7 (MA), hired on 3/24/21; Staff 8 (MA), hired on 6/12/20; Staff 9 (MA), hired 3/26/21; Staff 10 (MA/CG), hired 3/21/21; and Staff 12 (MA), hired on 5/12/20 lacked documented evidence an observation and evaluation had been completed which determined their ability to perform safe medication and treatment administration unsupervised, and lacked documented evidence of training and competency demonstration in the following areas: * Role of service plans in providing individualized care;* Providing assistance with ADL's;* Identification, documentation and reporting of changes of condition;* Conditions that require assessment, treatment, observation and reporting; * General food safety, serving and sanitation;* Environmental factors that affect dementia care;* The role of family in dementia care;* Recognizing behaviors that require assessment;* Use of supportive devices;* Changes associated with normal aging; and* Med Tech training to administer medications.2. Staff 13 (CG) was hired on 7/14/19. Review of the facility training records revealed Staff 13 did not complete 16 hours of annual training related to provisions of care in CBC, including six hours related to dementia care.The need to ensure all newly hired staff completed pre-service orientation before and all veteran staff completed 16 hours of annual training was discussed with Staff 1 (Interim Director of Operations), on 4/2/21. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure that 1 of 4 sampled residents, (#3), had a diagnosis of dementia and was in need of support for the progressive symptoms of dementia for safety, physical or cognitive function prior to being admitted to the memory care community. Findings include, but are not limited to:Resident 3 was admitted to the facility in 2018 with diagnoses including altered mental status, dysphasia (difficulty swallowing), and difficulty walking.On 3/30/21 review of clinical records for Resident 2 revealed no diagnosis of dementia. During an interview on 3/8/21 with Staff 2 (RN), the resident record was again reviewed and revealed no diagnosis for dementia or reason for a secured environment. The need to ensure that residents residing in the memory care community have a clear diagnosis of dementia which is progressive and requires a secured environment for residents' safety, physical or cognitive function was reviewed with Staff 1 (Interim Director of Operations) on 4/2/21. She 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 C252, C260, C262, C270, C280, C300, C303 and C310.

Based on observation, 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 residents' service plans, or were followed for 3 of 4 sampled residents (#s 1, 2 and 4) whose service plans were reviewed. Findings include, but are not limited to:Resident's 1, 2 and 4's current service plans were reviewed during survey. Each of the service plans lacked information, staff instructions related to individualized nutrition and hydration status and needs, or were not followed by staff members providing care.The need to develop individualized service plans addressing residents' nutrition and hydration needs, and ensure that any plans that were in place were followed, was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.

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 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose service plans were reviewed. Findings include, but are not limited to:Though Resident 1, 2, 3 and 4's service plans offered some information about the resident's interests, the facility had not fully evaluated the resident's: * 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. There was no specific activity plan which detailed what, when, how and how often staff should offer and assist the resident with more individualized activities.The need to ensure the facility provided meaningful activities based on a thorough evaluation and individualized activity plan for each resident was discussed with Staff 1 (Interim Director of Operations) on 4/2/21. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents had access to an enclosed, secured outdoor area. Findings include, but are not limited to:On 3/30/21 at 10:55 am, the exit door to the outdoor courtyard area was observed to be locked. During an interview on 3/30/21 at approximately 11:15 am, Staff 1 (Interim Director of Operations) stated she was not aware the door was locked or that it needed to remain unlocked for residents to access the courtyard, at which time she was notified a staff member had unlocked the door at survey request. On 3/31/21, 4/1/21 and 4/2/21 the courtyard door was observed to be locked. Staff 1 was notified each day the door needed to remain unlocked for resident access. During the survey, the need to ensure residents had access to an enclosed secured outdoor area was discussed with Staff 1. She acknowledged the findings.