Fircrest Senior Living

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000.

Findings include, but are not limited to:

On 07/22/25 at 10:50 am, the facility kitchen was observed to need cleaning in the following areas:

* Interior of ice maker – build up of pink matter;

* Exterior doors and vents below doors, lower interior shelves of freezers and refrigerators – smears/food drips/debris/dried and/or frozen food spills;

* Upper shelves above two and three compartment sinks – debris/dust build up;

* Splash guard on commercial stand mixer – food splatter;

* Commercial can opener blade – food debris;

* Lower shelf containing mixer bowl and attachments – debris/spills;

* Food bin lids in dry food storage – food debris build up;

* Operating window air conditioner - dusty;

* Sides of stove – drips/spills;

* Area below oven door – build up of black matter/grease;

* Lower shelf next to stove – debris/grease/dust;

* Fan operating next to service line – dusty;

* Cabinet door exteriors and door tracks on front side of service line – drips/spills/debris;

* Interior lower shelf of cabinet containing syrup, cereal, brown sugar, sauces – spills;

* Flooring and piping under dishwashing area – significant build up of black matter/dust;

* Wall behind dishwashing machine – build up of black/brown matter; and

* Top of dishwashing machine – build up of dried matter.

Improper food storage:

* Refrigerator #2 and #4 – open, undated and unlabeled food items (sliced cheese/pink mixture of cottage cheese and fruit/meat patty); and

* Dry food storage – multiple food containers with unsecure lids.

The areas of concern were observed and discussed with Staff 1 (Dietary Manager) and discussed with Staff 2 (Med Tech), Staff 3 (RDO), Staff 4 (LN) and Staff 5 (ALF Administrator) on 07/22/25. The findings were acknowledged.

OAR 411-054-0030 (1)(a) Resident Services Meals, Food Sanitation Rule

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

This Rule is not met as evidenced by:

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities.

Findings include, but are not limited to:

Refer to C240.

OAR 411-057-0140(2) Administration Compliance

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

This Rule is not met as evidenced by:

The findings of the re-licensure survey, conducted 07/08/24 through 07/11/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities, and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules. Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 07/11/24, conducted 09/23/24 through 09/25/24, 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 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the second revisit to the re-licensure survey of 07/11/24, conducted 12/30/24 through 12/31/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day



The findings of the third revisit to the relicensure survey of 07/11/24, conducted 03/11/25, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities, and OARs 411 Division 004 Home and Community Based Services Regulations.

Based on observation, interview, and record review, it was determined the facility failed to ensure residents' right to be treated with dignity and respect for 1 of 2 sampled residents and two unsampled residents who received meal assistance and ADL care, and to receive services in a manner that protected privacy and dignity for 1 of 1 sampled resident (#8) who received care at bedside. Findings include, but are not limited to: 1. Meal service observations were made during the survey on 09/24/24. On 09/24/24 at 12:12 pm, meal observations were conducted in the facility's activities room, which served as a secondary dining area. Resident 8 and three unsampled residents were receiving meal assistance from Staff 8 (CG) and Staff 9 (CG).During the meal service, and while providing direct care to the residents, Staff 8 and Staff 9 continuously spoke to each other in a language other than which the residents could understand. The need to ensure residents' right to be treated with dignity and respect was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator) on 09/25/24. They acknowledge the findings.
2. Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia.The current service plan, dated 09/23/24 identified the resident had the following care needs:* Two-person assist for transfers using a hoyer lift; and* Full assist with toileting and perineal care. Observations of Resident 8's room revealed s/he shared a room with another resident. Staff 8 (CG), Staff 10 (CG) and Staff 22 (CG) were observed providing incontinence care and transfer assistance from bed to wheelchair for Resident 8 while his/her roommate was in the room. There was no observable barrier between the two sides of the room that provided privacy and dignity during ADL cares.In addition, Staff 8, Staff 9 and Staff 22 continuously spoke to each other in a language that the resident could not understand. An interview at 12:00 pm on 09/25/24 Staff 3 (Lead MT) acknowledged that the staff were supposed to escort the resident outside of the room or use a privacy screen when assisting Resident 8. The need to ensure residents' right to be treated with dignity and respect, and receive services in a manner to protect privacy was discussed with Staff 1 (ED), Staff 2 (LPN, Residential Services Coordinator) and Staff 3 on 09/25/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure any incident of abuse or suspected abuse was reported to the local SPD office or the local AAA, promptly investigated all reports of abuse and suspected abuse and took measures necessary to protect residents and prevent the reoccurrence of abuse for 1 of 1 sampled resident (#10) who incidents were reviewed. Findings include, but are not limited to:Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia.The resident's 09/20/24 service plan, 09/09/24 through 09/24/24 progress notes, an incident report, and Temporary Service Plans (TSP)'s were reviewed, and observations and interviews were conducted. The facility failed to immediately report abuse or suspected abuse to the local SPD office and promptly investigate all reports of abuse and suspected abuse for the following incident:09/09/24 - Progress notes indicated Resident 10 was sitting on the couch in another resident's room when the Activity Director entered with one of the residents who occupied that room. When s/he was asked "politely" by staff to leave, Resident 10 began yelling and knocked the staff to the floor. "The other resident in the living room tried to intervene by yelling at [him/her] to stop before [Resident 10] got up in [his/her] face as well [sic] threatening to do something about [him/her] next." On 09/25/24 at 10:35 am, an interview with Staff 1 (ED) indicated she was not working at the time and confirmed the incident was not reported to the local SPD office. On 09/25/24 at 10:45 am, an interview with Staff 2 (LPN/Resident Services Coordinator), who was covering at the time, confirmed there was no investigation and he had not completed "a TSP because by the time I got there the residents had been separated out of that room", Resident 10's spouse got him/her to leave the room "and [Resident 10] was fine". The need to ensure all incidents of abuse were immediately reported to the local SPD office and investigated was discussed with Staff 1 and Staff 2 on 09/25/24 at 12:00 pm. They acknowledged the findings.On 09/25/24, survey requested the facility report the incident to the local SPD office, verification was received prior to exit.
Based on observation, interview and record review, it was determined the facility failed to investigate an injury of unknown cause or unwitnessed fall to rule out possible abuse or report to the local SPD office if abuse could not be ruled out for 1 of 2 sampled residents (#11) whose incidents were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 11 was admitted to the memory care facility in 08/2023 with diagnoses including dementia.a. During the acuity interview on 12/30/24, the resident was identified as requiring full assistance with all ADLs, including a two-person assist for transfers and 1:1 assistance during meals.On 12/30/24 at 11:07 am, the resident was observed with a dressing on the left elbow area.A 12/24/24 Skin Impairment note showed "skin tear noted to left elbow".There was no documented evidence the facility conducted an investigation to determine the cause of the skin injury. The incident was not reported to the local SPD office. The surveyor requested Staff 1 (ED) and Staff 2 (Residential Services Coordinator, LPN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit.b. The resident's clinical record dated 11/01/24 through 12/19/24, and an 11/15/24 incident report were reviewed during the survey and revealed the following:* 11/15/24 progress note: "Resident on alert for an unwitnessed fall ..."; and* 11/15/24 incident report: the resident was found on the floor next to his/her bed. It appeared the resident slid off the side of the bed due to not being positioned properly in the center of the bed.The service plan dated 11/21/24 instructed staff to ensure the resident was positioned in the center of the bed before leaving the room after providing care. The plan was implemented on 10/11/24.There was no documented evidence indicating the facility determined how the incident was ruled out as abuse or neglect, especially since staff did not follow the service plan. The incident was not reported to the local SPD office. The surveyor requested Staff 1 (ED) and Staff 2 (Residential Services Coordinator, LPN) report the incident to the local SPD office. A copy of confirmation that the report was sent to the SPD office was provided prior to exit.The need to ensure injuries of unknown cause and unwitnessed falls were immediately investigated by the facility, and if abuse was not able to be reasonably ruled out, the incidents were reported to the local SPD office, was discussed with Staff 1, Staff 2 and Staff 3 (Lead MA) on 12/31/24 at 11:25 am. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure move-in evaluations addressed all required elements for 1 of 1 sampled resident (#7) whose evaluation was reviewed. Findings include, but are not limited to:Resident 7 was admitted to the facility in 03/2024 with diagnoses including dementia.The Move-In Evaluation, dated 03/29/24, was reviewed and revealed missing information in the following required elements: * Customary routines regarding sleeping, eating, and bathing; * List of medications and PRN use; * Personality including how the person copes with change or challenging situations; * Ability to understand and be understood; * Non-pharmaceutical interventions for pain; * Nutrition habits, fluid preferences, and weight if indicated; and * Complex medication regimen. The need to ensure the move-in evaluation addressed all required elements was discussed with Staff 1 (ED) on 07/10/24. She 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 care needs and provided clear direction to staff regarding the delivery of services for 2 of 5 sampled residents (#s 3 and 6) whose service plans were reviewed. Findings include, but are not limited to:1. Resident 3 was admitted to the facility in 11/2017 with diagnoses including dementia. The resident's service plan, dated 06/26/24, and Temporary Service Plans were reviewed. Resident 3 was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas: * Ability to take self to the restroom; * Interventions when the resident yelled at the roommate; * How Resident 3 communicated when other residents were getting too close to him/her; * Changing staff members when the resident was reluctant to receiving care; * Ability to get self ready for bed; and * Where the resident preferred to eat their meals. The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident's service plan, dated 06/24/24, Temporary Service Plans and progress notes, dated 04/09/24 through 07/05/24, were reviewed. The resident was observed and staff were interviewed. The service plan lacked information relating to the resident's current needs and/or clear caregiving instruction in the following areas: * Apartment door alarm; * Hearing; and * Toileting assistance. The need to ensure service plans were reflective of the resident's current needs and provided clear caregiving instruction was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. 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' needs and preferences, provided clear direction regarding the delivery of services, and services were implemented for 2 of 4 sampled residents (#s 8 and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia. Observations of the resident, interviews with staff and review of the most recent service plan, dated 09/23/24, showed the service plan was not reflective of the resident's current care needs, did not provide clear direction to staff and/or was not being implemented in the following areas: * Use of heel protectors and pillow between legs for skin integrity when in bed; * Use of washcloth in contracted hand;* Positioning in the wheelchair for comfort and skin integrity from rigid footplates; and* How long to be sitting up in the wheelchair. The need to ensure resident service plans were reflective of current care needs, provided clear direction to staff, and were implemented was discussed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.2. Resident 10 was admitted to the facility in 09/2024 with diagnoses including bilateral osteoarthritis of knee, psychotic disturbance, and dementia. Observations of the resident, interviews with staff and review of the most recent service plan, dated 09/20/24, and a Temporary Service Plan (TSP), dated 09/11/24, showed the service plan was not reflective of the resident's current care needs and did not provide clear direction to staff in the following areas:* Non-pharmacological interventions for pain and location of the pain;* Resident-specific behavioral interventions for prevention of further resident to resident behaviors; and* Showering schedule including preferences for time of day.The need to ensure resident service plans were reflective of current care needs and provided clear direction to staff was discussed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.

Based on observation, interview and record review, it was determined the facility failed to ensure the implementation of service for 1 of 2 sampled residents (#11) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:Resident 11 was admitted to the facility in 08/2023 with diagnoses including dementia.During the survey, the resident was observed to have contractions in the right hand, with the fingers tightly clenched and the hand fixed in a fist like position. Additionally, the resident was transferred with the assistance of two staff who placed their arms under the resident's armpits during the transfer. Observations of the resident, interviews with staff, and the 11/21/24 service plan reviewed during the survey showed staff did not implement the outlined service plan in the following areas:* Transfer status including the use of a gait belt; and* Place a cloth in the right hand to help prevent yeast build up.On 12/31/24 at 11:25 am, not implementing the outlined service plan was discussed with Staff 1 (ED), Staff 2 (Residential Services Coordinator, LPN) and Staff 3 (Lead MA). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols for 1 of 1 sampled resident (#8) who was observed receiving ADL care at bedside and meal assistance. Findings include, but are not limited to: Resident 8 was admitted to the facility in 04/2023 with diagnoses including dementia. The current service plan, dated 09/23/24, identified the resident had the following care needs:* Feeding assistance from staff; * Two-person assist for transfers using a hoyer lift; and* Full assist with toileting and perineal care. a. On 09/24/24, meal observations were conducted in the facility's activities room, which served as a secondary dining area. At 12:16 pm, Staff 9 was observed handling a resident's soiled plate with the thumb of her ungloved left hand on the surface of the plate. When she returned the plate to the table, she picked up the resident's used cup with the ungloved left hand, placing her fingers near the rim of the cup. After Staff 9 returned the cup to the resident, she sat next to Resident 8, picked up a napkin with the ungloved left hand and began wiping Resident 8's mouth with the napkin. Staff 9 was not observed to have preformed hand hygiene after handling the soiled dishware and prior to assisting Resident 8. On 09/25/24, the need to ensure staff used universal precautions when providing care to residents was discussed with Staff 1 (ED) and Staff 2 (LPN, Residential Services Coordinator). They acknowledged the findings.
b. During an ADL observation with Resident 8 on 09/24/24 at 11:05 am, the following was observed:* Three caregiving staff donned gloves and assisted the resident with incontinence care, which included physical assistance with rolling, perineal care, and repositioning;* All three staff assisted in removing the soiled brief;* One staff provided perineal care that included using wipes. All three staff then touched a clean incontinence brief, the resident's legs and torso, clothing, heel protectors, the bedding, and the hoyer sling, all while wearing the soiled gloves; * The staff who cleaned the perineal area then used the controls of the hoyer lift while the other two staff touched the handles, back and footplate's of the wheelchair; and* The staff who cleaned the perineal area removed the soiled gloves and performed hand hygiene prior to leaving the resident's room. The other two staff remained in the room and made the resident's bed and assisted Resident 8's roommate who was also in the room without changing soiled gloves.The need to maintain effective infection prevention and control while providing ADL care was reviewed with Staff 1 (ED), Staff 2 (LPN/Resident Services Coordinator) and Staff 3 (Lead MT) on 09/25/24 at 12:00 pm. They acknowledged the findings.
2a. During an ADL observation on 12/30/24 from 1:03 pm to 1:14 pm the following was noted:The surveyor obtained permission and observed Staff 12 (CG) and Staff 16 (CG) provided incontinence care to Resident 11. Both staff wore single-use gloves while assisting the resident with transferring from the wheelchair to the bed. The staff then helped with personal care by removing a soiled brief, cleaning the perineal area and putting on a clean brief using the same gloves. The staff then touched the resident's blanket, assisted with dressing the lower body, and transferred the resident from the bed to the recliner while wearing the same gloves. During the observation, both staff did not change their gloves or wash their hands between clean and dirty tasks. 2b. During an observation on 12/31/24 from 11:04 am to 11:12 am the following was noted:The surveyor obtained permission and observed Staff 13 (CG) and Staff 23 (CG) provide incontinent care to Resident 11. Staff 23 removed the resident's soiled brief and removed the gloves, then used hand sanitizer to clean their hands before putting on a new pair of gloves. Afterward, Staff 13 and Staff 23 assisted the resident with repositioning and lower body dressing. However, after removing the soiled brief, the resident's perineal area was not cleaned or wiped. Both staff assisted the resident with putting on lower body clothing including a clean brief and pants after removing the soiled brief without cleaning the resident's perineal area. The need to ensure proper infection control was utilized during the incontinence care and hand hygiene was discussed with Staff 1 (ED), Staff 2 (Residential Service Coordinator, LPN) and Staff 3 (Lead MA) on 12/31/24 at 11:25 am. They acknowledged the findings.
Based on observation and interview, it was determined the facility failed to maintain infection prevention and control protocols to provide a safe, sanitary environment for 1 of 2 sampled residents (# 11) and 1 of 1 unsampled residents who received incontinence care. This is a repeat citation. Findings include, but are not limited to:1. During an ADL observation on 12/30/24 at 1:50 pm the following was noted: Staff 12 (CG) and Staff 24 (CG) donned their gloves and assisted an unsampled resident to the bathroom. Staff 24 assisted the resident to remain standing while Staff 12 doffed the resident's pants, removed the soiled brief, put it in the trash can, and removed the resident's soiled pants. Staff 24 assisted the resident to sit on the toilet. Without changing the soiled gloves or performing hand hygiene, Staff 12 assisted the resident with a clean brief and clean pants. Both caregivers then doffed their soiled gloves, and assisted the resident to stand up. The caregivers were observed leaving the resident's apartment, and then going to another room. There was no observation of hand hygiene. The need to ensure proper infection control and hand hygiene was utilized during incontinence care was discussed with Staff 1 (ED), Staff 2 (Residential Service Coordinator, LPN), and Staff 3 (Lead MA) on 12/31/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure a system was in place to track controlled substances for 1 of 1 sampled resident (#4) who was administered prescribed PRN narcotic medication. Findings include, but are not limited to:Resident 4 was admitted to the facility in 07/2023 with diagnoses including dementia and chronic obstructive pulmonary disease. The resident's 06/01/24 through 07/08/24 MARs and physician orders were reviewed. The following was identified:* The resident had a physician order for Hydrocod/APAP 5/325 mg tab, one tablet every six hours as needed for severe pain.* The 06/01/24 through 07/08/24 MAR revealed the resident was administered the PRN narcotic on 31 occasions in 06/2024 and on nine occasions between 07/01/24 and 07/08/24.* The Controlled Substance Distribution log contained nine entries for 06/2024 and five entries for 07/2024, which were not reflected on the MARs.* The number of tablets remaining noted in the Controlled Substance Distribution log matched the number of tablets remaining on the corresponding medication cards.The need to ensure a system was in place for tracking controlled substances was discussed with Staff 1 (ED), Staff 2 (LPN), and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.

2. Resident 6 was admitted to the facility in 02/2023 with diagnoses including dementia. The resident's 06/01/24 through 07/08/24 MARs, physician's orders, and progress notes, dated 04/09/24 through 07/05/24, were reviewed. The following was identified:a. There were medications which were not initialed as administered with no indication whether or not the medication had been administered for the following dates and times: * 06/24/24 at 8:00 am: Buspirone (for sexual behaviors), Eliquis (for atrial flutter), Lisinopril (for hypertension), metoprolol (for atrial flutter and hypertension), andsertraline (for dementia); and * 07/01/24 at 8:00 am: Sertraline. b. Staff documented the resident's buspirone could not be administered as they were "waiting on delivery" from 06/22/24 through 06/26/24 and from 06/30/24 through 07/03/24. Staff initialed the MAR indicating the buspirone was administered nine times during the dates that the medication was not available. The need to ensure the accuracy of MARs was discussed with Staff 1 (ED) on 07/10/24. She acknowledged the findings.
Based on interview and record review, it was determined the facility failed to ensure an accurate MAR was kept for all medications ordered by a physician or other legally recognized prescriber for 2 of 4 sampled residents (#s 5 and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 06/2021 with diagnoses including dementia.The resident's 06/01/24 through 07/08/24 MARs were reviewed. The following was identified:* On 06/26/24 there were seven medications which were not initial as administered at 8:00 pm. There was no indication whether or not the medication had been administered.In an interview on 07/11/24 at 9:35 am, Staff 1 (ED) and Staff 3 (Lead MT) stated it was "probably" the MT working that shift "got busy" and neglected to enter the administration time in the electronic MAR.The need to ensure all medication administered to residents was documented accurately in the MAR was discussed with Staff 1 and Staff 2 on 07/11/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to document all required elements for fire drills in accordance with the Oregon Fire Code (OFC) and failed to ensure fire and life safety instruction was provided to staff on alternate months. Findings include, but are not limited to:Review of fire drill and fire and life safety records for 01/2024 through 07/2024 identified the following:a. The fire drill records lacked documentation of the following components:* Location of simulated fire origin;* Escape route used; and* Problems encountered.b. The facility lacked documented evidence fire and life safety instruction was provided to staff on alternate months of fire drills and the content of the training was related to fire and life safety.On 07/11/24, the need to ensure all required components of fire drills were documented and fire and life safety instruction to staff was provided on alternate months was discussed with Staff 1 (ED) and Staff 3 (Lead MT). They acknowledged the findings.

Based on observation, 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 C260.
Based on observation, 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. This is a repeat citation. Findings include but are not limited to:Refer to C231, C260, and C295.

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 C 420.

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 C200, C231, and C295.

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 and C295.

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 302, and C 310.

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. This is a repeat citation. Findings include, but are not limited to:Refer to C260.

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. This is a repeat citation. Findings include, but are not limited to:Refer to C260.

Based on interview and record review, it was determined the facility failed to ensure an individualized nutrition and hydration plan was developed for each resident and was included in the service plan for 5 of 5 sampled residents (#s 1, 2, 3, 5 and 6) whose nutrition and hydration plans were reviewed. Findings include, but are not limited to:Residents 1, 2, 3, 5, and 6's current service plans were reviewed during survey. Each service plan lacked information and/or staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident.The need to develop a daily meal program based on the resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (ED) and Staff 3 (Lead MT) on 07/11/24. They acknowledged the findings.

Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 02/01/22. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar cc: cubic centimeterCG: caregivercm: centimeterF: FahrenheitHH: Home HealthHS or hs: hour of sleepLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterO2 sats: oxygen saturation in the bloodOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayRN: Registered NurseSP: service planTAR: Treatment Administration Recordtid: three times a day

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to implement a policy for the referral of residents who may be victims of acute sexual assault to the nearest trained sexual assault examiner within 86 hours. Resident 1 was not referred to the nearest trained sexual assault examiner within 86 hours following a possible sexual assault. Findings include, but are not limited to:An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been ruled out.An email from Staff 2 (LPN) to the Department, dated 06/05/24, indicated "There were no signs of sexual abuse or sexual activity. I performed an assessment on the female resident and found no signs of abuse such as bruising, bleeding, or tearing."During an interview on 06/05/24, Staff 2 (LPN) stated the following:- S/he had performed an evaluation and ruled out sexual abuse;- Staff 2 was not a trained sexual assault examiner;- S/he was unaware of the requirement to refer residents who may be victims of sexual assault the nearest trained sexual assault examiner within 86 hours; and- Resident 1 had not been referred to the nearest sexual assault examiner.An incident report, dated 05/31/24, indicated the following:- Resident 1 had been found in Resident 2's room;- Resident 1 and Resident 2 were unclothed;- Resident 2 was attempting to penetrate Resident 1 sexually;- An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and- Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old."During an interview on 06/05/24, Staff 2 stated s/he had conducted the assessment of Resident 1 on 05/31/24. S/he again stated s/he was not a trained sexual assault examiner.An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by a staff member on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching himself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted."In an interview Staff 2 again stated s/he had performed the assessment of Resident 1 on 06/02/24.The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "Initial Interventions: ... Call 911. Report suspicion of acute sexual assault and request transportation via ambulance to the E.R. for examination by a trained Sexual Assault Examiner (SAE)." Resident 1 was observed to be transported by ambulance at approximately 10:22 pm on 06/05/24, approximately 89 hours after the incident on 06/02/24. Staff 2 stated Resident 1 was being transported for a sexual assault assessment.During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself.Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss."The facility failed to refer Resident 1 to the nearest trained sexual assault examiner within 86 hours, resulting in possible degradation of evidence.LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).The Department placed a condition on the facility on 06/07/24.

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to monitor a resident consistent with his or her evaluated needs and service plan. The facility was to provide one-on-one supervision for the safety of Resident 1 and failed to do so. Findings include, but are not limited to:An incident report, dated 05/30/24, indicated Resident 1 was found in Resident 2's room undressed, and Resident 2 was in the process of undressing. It further indicated sexual abuse had been "ruled out."During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had moved rooms.An incident report, dated 05/31/24, indicated the following:- Resident 1 had been found in Resident 2's room;- Resident 1 and Resident 2 were unclothed;- Resident 2 was attempting to penetrate Resident 1 sexually;- An assessment had been conducted on Resident 1 and there were "no signs of sexual abuse noted;" and- Resident 1 had "small yellowing bruises on [his/her] right buttock that appeared to be days old."During an interview on 06/05/24, Staff 2 (LPN) stated Resident 1 had been placed on 15-minute checks on 05/31/24 and placed under 1-on-1 supervision on 06/01/24. S/he further stated the facility RN had not been notified of the incidents on 05/30/24, 05/31/24, 06/02/24, or 06/04/24 as of approximately 6:35 pm on 06/05/24.Fifteen-minute safety check logs for Resident 1 obtained on 06/05/24 were dated 06/02/24 through 06/05/24. There was no prior documented evidence 15-minute safety checks had been implemented for Resident 1.A temporary service plan, dated 06/01/24, indicated Resident 1 "needs to be 1-on-1 with a care staff at all times to ensure [his/her] safety."Staff training documentation for Resident 1's 1-on-1 requirement indicated staff signed the document on 06/05/24.An incident report, dated 06/02/24, indicated that at approximately 5:00 am Resident 1 had been found by staff on Resident 3's bed. Resident 1 was fully clothed, while Resident 3 was partially undressed and touching his/herself sexually over Resident 1. It further indicated "no signs of sexual abuse were noted."In an interview on 06/05/24, Staff 3 (Lead Med Tech) stated the employee that was supposed to be doing the 1-on-1 had been suspended. S/he further stated the 15-minute safety check log had been started on 06/02/24 and the 1-on-1 supervision had been in place before 06/02/24.An incident report, dated 06/04/24, indicated Resident 1 had been found cornered by Resident 3, in Resident 3's shower, with his/her back up against the wall.During an interview on 06/05/24, Staff 6 (Med Tech) stated the following:- "Shortly after the first incident" 15 minute checks and 1-on-1 put in place;- "There's been a few things I believe [since the first incident] ... at least two additional [incidents];"- "I was here last night, I saw that [the incident with Residents 1 and 3 in the shower] with my own eyes;" and- "The person that was supposed to be 1-on-1 [with Resident 1] had laid [him/her] down and was doing hall room checks."During an interview on 06/06/24, Witness 1 (Hospice RN) stated "No, [Resident 1] can't consent to anything." S/he further stated Resident 1 was incapable of undressing his/herself.Resident 1's service plan, dated 03/12/24, indicated s/he required "care staff to assist [Resident 1] with all undressing and dressing needs," "demonstrates inappropriate judgment, behavior, and ability to function in social settings," and "has severe memory loss."The facility's failure to monitor Resident 1 consistent with his/her evaluated needs, by providing one-on-one supervision, placed Resident 1 at repeated risk of further harm.LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2, Staff 3, Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).The Department placed a condition on the facility on 06/07/24.

Based on interview and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to ensure the facility RN is notified of nursing needs for 1 of 1 sampled resident (# 1). Findings include, but are not limited to:The facility's "Intimacy/Sexual Intimacy/Sexual Assault" policy indicated "When residents express a desire to have an intimate/sexual relationship, the facility administrator and the facility RN will be notified and immediate steps taken to determine interventions related to the residents' intimacy and sexual needs ... If abuse is alleged or suspected, follow the processes described in the Abuse Policies and / or the sexual assault process above."During an interview on 06/05/24, Staff 2 (LPN) stated s/he had not notified the facility RN of multiple incidents of possible sexual assault occurring on 05/30/24, 05/31/24, and 06/02/24 involving Residents 1, 2, and 3 as of 06/05/24.During an interview on 06/07/24, Staff 10 (RN) stated s/he had not been notified of multiple incidents involving Resident 1 until 06/07/24.There was no documented evidence the facility RN had been notified of the incidents involving Resident 1 by 06/05/24.LCU requested a safety plan for Resident 1 on 06/05/24 at approximately 8:30 pm.A safety plan for Resident 1 was provided by the facility and accepted by LCU at approximately 10:25 pm.It was determined the facility failed to ensure the facility RN was notified of nursing needs for a resident.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).The Department placed a condition on the facility on 06/07/24.

Based on observation, interview, and record review, conducted during a site visit on 06/05/24 and 06/07/24, and interviews on 06/06/24, it was confirmed the facility failed to provide effective administrative oversight over the operation of the Memory Care Community (MCC). 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 LCU investigation, conducted 06/05/24 through 06/07/24, administrative oversight to ensure adequate resident care and services was found to be ineffective based on the severity of citations in the following areas:OAR 411-054-0025(7)(f) Facility Adminstration;OAR 411-054-0040(2)(a) Change of Condition and Monitoring; andOAR 411-054-0045(1)(d) Resident Health Services. LCU requested a safety plan for Residents 1, 2, and 3 on 06/05/24 at approximately 8:30 pm.Safety plans for Residents 1, 2, and 3, were provided by the facility and accepted by LCU at approximately 10:25 pm.The findings of the investigation were reviewed with and acknowledged by Staff 1 (Regional Administrator), Staff 2 (LPN), Staff 3 (Lead Med Tech), Staff 8 (Assisted Living Administrator), and Staff 9 (Vice President).The Department placed a condition on the facility on 06/07/24.

The findings of the kitchen inspection, conducted 04/03/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the first revisit to the kitchen inspection of 04/03/24, conducted 07/09/24 through 07/10/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the second revisit to the kitchen inspection of 04/03/24, conducted 09/05/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

The findings of the third re-visit to the kitchen inspection of 04/03/24, conducted on 10/30/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services- Meals, and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.

Based on observation and interview, it was determined the facility failed to ensure kitchen practices and protocols were in accordance with the Food Sanitation Rules OARs 333-150-0000. Findings include, but are not limited to: On 04/03/24 at 11:15 am, the facility kitchen was observed to need cleaning in the following areas: a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following: * Bottom shelf of the counter top refrigerator next to coffee maker; - food debris/spills on bottom shelf, freezer with significant ice buildup;* Vents below the doors of refrigerators #2 and #4; * Bottom shelves and vents below the doors of Freezers #1 and #2; * The oven doors and sides of stove/grill; * The hood vents above the stove/grill;* The lower shelves of counters and preparation areas throughout the kitchen including: - counters next to stove/grill; - holding mixer attachments; - cupboards with doors in front of steam table holding clean dishes; - under steam table;* Walls and ceiling throughout the kitchen including: - in the dishwashing area below the rack shelf; - behind the spray hose and dishwasher; - wall area above and below counter holding blenders next to the stove/grill; - wall surrounding handwashing sink behind the stove wall & underneath sink areas; - wall area behind the three sink area; - above the window air conditioner; - wall next to the exterior door; - ceiling vents above steam table; and - pan storage area;* Window air conditioner, which was in operation (blowing air) creating potential for cross contamination;* Food slicer and holding shelf beneath the slicer; and * Flooring throughout the kitchen, including: dry storage area; dishwashing area; corners and underneath counters and storage shelves.b. Other findings included: *Freezer #1 - not all food items were frozen solid, temperature at 30 degrees F;* Refrigerators #2, #4 and freezer #1 contained containers and repackaged food items which were unlabeled/undated (imitation crab; pears; cut fruit; lunch meat; cheese slices);* Cardboard boxes of disposable containers and foil sheets were stored on the floor in dry storage area; and*One uncovered garbage can. The findings were discussed with Staff 1 (Med Tech serving as kitchen PIC), Staff 2 (Executive Director) and Staff 3 (ALF Administrator) on 04/03/24. The findings were acknowledged.

Based on observation and interview, it was determined the facility failed to ensure the kitchen was clean, in good repair, and food was stored appropriately in accordance with the Food Sanitation Rules OAR 333-150-000. This is a repeat citation. Findings include, but are not limited to:On 07/09/24 at 9:30 am, the facility kitchen and memory care kitchenette were observed.a. Food spills, splatters, debris, dirt, dust, grease and/or black/brown matter was observed on or underneath the following: * Bottom shelf of the counter-top refrigerator next to coffee maker; * Stainless steel shelving, racks and carts throughout the kitchen;* The oven doors and sides of stove/grill; * The lower shelves of counters and preparation areas throughout the kitchen;* Stand mixer and mixer attachments; * Cupboards with doors in front of steam table holding clean dishes; * Shelving under steam table;* Walls and ceiling throughout the kitchen;* Light switch in dry storage room;* Paper towel dispenser near coffee station; and * Flooring throughout the kitchen.b. Items in need of repair included: * Ceiling areas throughout the kitchen had unsealed drywall and unfilled cracks or holes;* Cabinet containing clean dishes had corner laminate pieces missing which made the cabinet an uncleanable surface; and* Cutting boards had deep scratches and were scored.c. Other findings included: * Window air conditioner and two industrial fans, which were in operation (blowing air), were covered with dirt and debris creating the potential for cross contamination; * Refrigerators contained food items which were unlabeled and/or undated (lunch meat and cheese);* Bins in the dry storage room containing oatmeal, brown sugar, and rice were unsealed and open to air;* Two uncovered garbage cans; and* Two staff were not wearing hair restraints.d. Kitchenette findings included:* Unfinished cabinetry, which made the cabinets uncleanable surfaces, had staining.The findings were discussed with Staff 5 (Executive Chef), Staff 2(Executive Director) and on 07/10/24 at 1:15 pm. The findings were acknowledged.

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. This is a repeat citation. Findings include, but are not limited to:On 09/05/24 at 11:40 am, the facility kitchen and memory care kitchenette were observed, and the following was identified: * Floors throughout the kitchen had black matter build-up, food debris, and grease in corners, under equipment, and around perimeter edges;* Missing and damaged chunks of flooring were noted in the dishwashing area, under the ice machine, refrigerator, and freezer; * The wall behind the dishwashing area had black stains; * The caulking in the dishwashing area and behind the preparation counter had an accumulation of brown and black stains; and * The cabinets containing clean dishes had chipped and missing laminate with exposed porous wood areas. Kitchenette findings included:* Unfinished cabinetry, which made the cabinets uncleanable surfaces, had staining.On 09/05/24 at 1:30 pm, the findings were discussed with Staff 1 (MT), Staff 2 (Executive Director), Staff 4 (Assisted Living Administrator) and Staff 5 (Executive Chef). They acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. Findings include, but are not limited to:Refer to C 240.
Based on observation and interview, it was determined the facility failed to ensure their kitchen survey plan of correction was implemented and satisfied the Department. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

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

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

Based on observation and interview, it was determined the facility failed to follow licensing rules for Residential Care and Assisted Living Facilities. This is a repeat citation. Findings include, but are not limited to:Refer to C 240.

The findings of the re-licensure survey conducted 08/14/23 through 08/17/23 are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, OARs 411 Division 57 for Memory Care Communities 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 CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day
The findings of the first revisit to the re-licensure survey of 08/17/23, conducted 01/02/24 through 01/05/24, 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 for Home and Community Based Services Regulations.Tag numbers beginning with the letter C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a dayA situation was identified during the survey where failure of the facility to comply with the Department's rules was likely to cause residents serious harm. An immediate plan of correction was requested in the following area:OAR 411-054-0025 (4) Reasonable PrecautionsThe facility put an immediate plan of correction in place during the survey and the situation that could cause residents serious harm was abated.

The findings of the 2nd revisit to the re-licensure survey of 08/17/23, conducted 04/03/24 through 04/04/24, are documented in this report. The survey was conducted to determine compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities, Division 57 for Memory Care Communities and Home and Community Based Services Regulations OARs 411 Division 004.Tag numbers beginning with C refer to the Residential Care and Assisted Living Facilities rules. Tag numbers beginning with the letter Z refer to the Memory Care Community rules.Abbreviations possibly used in this document:ADL: activities of daily livingbid: twice a dayCBG: capillary blood glucose or blood sugar CG: caregivercm: centimeterED: Executive DirectorF: FahrenheitHH: Home HealthLPN: Licensed Practical NurseMA: Medication AideMAR: Medication Administration RecordMCC: Memory Care Communitymg: milligramml: milliliterMT: Medication TechnicianOT: Occupational TherapistPT: Physical TherapistPRN: as neededqd: every day or dailyqid: four times a dayQI: quality improvementRCC: Resident Care CoordinatorRN: Registered NurseTAR: Treatment Administration Recordtid: three times a day


The findings of the third revisit to the re-licensure survey of 08/17/23, conducted on 05/15/24, are documented in this report. It was determined the facility was in substantial compliance with the OARs 411 Division 54 for Residential Care and Assisted Living Facilities and Division 57 for Memory Care Communities.

Based on observation, interview, and record review, it was determined the facility failed to exercise reasonable precautions against any condition which could threaten the health, safety or welfare of residents for 3 of 3 sampled residents (#s 8, 9, and 10) who received inaccurate fluid consistencies. Residents received inaccurate fluid consistencies, placing them at risk for aspiration, choking and/or death. Findings include, but are not limited to:During the survey on 01/02/24, three sampled residents were identified as requiring modified texture meals and/or modified liquid consistencies.Resident 8, 9, and 10's clinical records were reviewed. Resident 8 had a physician order dated 12/14/23 for nectar thick consistency liquids. Resident 10 had a signed physician order, dated 11/25/22, indicating s/he required pureed textures and nectar thick liquids. Resident 9 had a physician order dated 10/09/23 for regular/thin diet and fluid consistency.Resident 8, 9, and 10's service plans revealed the following:*Resident 8's current service plan dated 11/21/23 noted the resident had a history of swallowing difficulties and required a pureed texture diet with pudding thick liquids. *Resident 9's current service plan dated 12/21/23 noted the resident was on a mechanical soft texture diet and no specifications for fluid consistency.*Resident 10's clinical record and current service plan dated 11/15/23 noted the resident was on a puree diet texture with nectar thick liquids.During meal observations of Resident 8, 9, and 10 and interviews with staff on 01/02/24 between 11:47 am and 1:15 pm, the following was noted:* Resident 8 required assistance to eat and drink during the noon meal;* Resident 8 had non-thickened water served at his/her place setting;* Staff 19 and 24 (CGs) were not able to state what fluid consistency the resident required;* Staff 24 removed the non-thickened water from the resident and served the resident nectar thick juice;* Staff 24 stated the resident needed "really" thick liquids and added approximately 1/4 cup of thickening agent to the juice;* Staff 19 (CG) spoon fed the juice with "pudding like consistency" to the resident; * Resident 10 required assistance to eat and drink during the noon meal;* Resident 10 had non-thickened water served at her/his place setting;* Staff 19 (CG) was not able to state what fluid consistency Resident 10 required;* Staff 24 (CG) removed the non-thickened water and stated Resident 10 was on a "thick liquid";* Prior to lunch being served, Resident 9 would stand up from the table and walk around the dining room and attempted to take other residents' silverware and/or drinks. Staff observed to intervene and give resident non-thickened glasses of water while walking around and/or when seated at the table. Resident 9 drank three glasses of non-thickened water prior to the noon meal. * Resident 9 required assistance to eat during the noon meal;* Staff 19 (CG) stirred a glass of water and gave to Resident 9 while s/he was eating. Staff 19 confirmed she had added powdered thickener to Resident 9's water but could not state what fluid consistency the resident required;* Staff 24 (CG) stated Resident 9 was nectar thick; and * Resident 9 was observed to drink the water provided by Staff 19. Resident 8, 9 and 10 either received thickened liquid without an order or received the incorrect fluid consistency. Staff 19 and 24 were unaware of what consistency the resident's required and were not clear on how much thickening agent to add to liquids. The facility failed to ensure residents who required modified fluid consistencies were served the appropriate fluid as evaluated or prescribed. This placed the residents at risk for choking, aspiration, and/or death.On 01/02/23 Staff 27 (Lead Cook) stated that the facility used pre-thickened water but the facility currently did not have any. Staff 3 (Lead Med Tech) stated the facility started using the powdered thickening agent "last week" when the pre-thickened water was not delivered by the food company. She acknowledged the staff should have received some training in using the powder to thicken liquids.The need to ensure the facility exercised reasonable precautions against any condition which could threaten the health, safety, or welfare of residents was discussed with Staff 1 (ED) on 01/02/24 at 1:25 pm. An immediate plan of correction was requested by the survey team on 01/02/24 at 2:30 pm. The IJ plan of correction was presented to the surveyors and approved on 01/02/24 at 3:35 pm. The situation was abated.* What actions will be taken to correct the rule violation for providing appropriate thickened liquids;1. Staff training was provided for all staff in attendance today by Executive Director, Beth Jones.2. The Executive Director and lead med tech will monitor for appropriate diets and feeding techniques until all staff have received training and competency verified starting today. 3. Pre-thickened liquids are available as of today to eliminate care staff need to mix fluids. 4. Simple directions for mixing thickened liquids will be posted for care staff with glass size to ensure correct thickness in case of emergency with no pre-thickened liquid available.5. Staff will receive training on Friday 01/05/2024 in an all staff meeting on providing appropriate thickened liquids. Those not in attendance will not assist in the dining room until training is documented. This training will be provided by Exec Director, Beth Jones. Janelle Asai, RD, or Vicki Pardon LD with Crandell Dietitians have been requested to provide in-service. ED will update if dietitians are unavailable for that date. 6. The Executive Director will maintain the correct inventory of thickened liquids. * How will the system be corrected so this violation will not happen again;1. Care staff will be trained in modified fluid textures at time of hire by qualified staff member. Competency will be verified prior to feeding residents. 2. All new staff who assist in the dining room will receive training on modified diets and thickened liquids prior to assisting residents in the dining room. 3. After initial training, training on proper textures and diets will be conducted quarterly via all staff meetings. 4. Diet orders will be reviewed quarterly and with Change of Condition by the service planning team (ED, Food Service Director, RSC and lead Med Tech). * How often will the area needing correction be evaluated; and1. The Executive Director will watch a meal service (random Breakfast, Lunch, Dinner), snack time to monitor for safety or staff training needs for 6 weeks and twice monthly after that. 2. The Executive Director will assign appropriately trained Med Tech, Lead Med tech or RSC on each shift is trained to assure quality control during all mealtimes starting today. * Who will be responsible for seeing that the corrections are completed?1. The Executive Director, Lead Med Tech and Food Service Director will be responsible.

Based on observation and interview, it was determined the facility failed to ensure resident's right to privacy and dignity was maintained related to providing ADL care for 1 of 3 sampled residents (# 8) whose ADL care was observed. Findings include, but are not limited to:Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia and shared an apartment with a non-sampled resident.Observation and interviews with staff during the survey identified Resident 8 as dependent on staff for ADL care. Resident 8 required two person assist with ADL care including incontinent care which was provided while the resident was in bed.During an ADL observation on 01/03/24 at 1:28 pm in the resident apartment, Staff 24 (CG) and Staff 25 (Life Enrichment Coordinator) provided the following:* Two person transfer lifting the resident from a wheelchair into bed;* Cueing and directions regarding incontinency care was provided;* The resident's pants were removed and then the soiled incontinent brief was removed;* Perineal care was provided using multiple incontinency wipes;* Clean incontinent brief was put on the resident; and* Resident 8 was repositioned in bed and a blanket was used to cover his/her lower body.The ADL care was provided in the resident apartment in the presence of the roommate and a lack of a privacy curtain. The need to ensure privacy and maintain resident dignity while providing incontinent care for Resident 8 was discussed with Staff 24 and Staff 25. Staff acknowledged the lack of privacy and stated they would utilize a privacy curtain.A privacy curtain was observed in Resident 8's room on 01/04/24 at 10:00 am.The lack of privacy and dignity afforded to Resident 8 was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am. Staff acknowledged the finding.

3. Resident 3 was admitted to the facility in 07/2019 with diagnoses including dementia.Interviews with care staff and observations of Resident 3 during the survey revealed they had recently suffered an upper extremity fracture that required staff assistance to don and doff a wrist brace, and also received weekly outside provider visits.Resident 3's current service plan, dated 07/16/23, failed to provide specific instruction to staff in the following areas:* Presence of wounds and healing upper extremity fracture;* Home Health wound care treatments in and out of facility; and* Instructions for assisting with upper extremity brace. 4. Resident 2 was admitted to the facility in 08/2023 with diagnoses including dementia.Interviews with care staff and observations of Resident 2 during the survey revealed they had started receiving home health services for a toe wound, however, the service had not been added to Resident 2's service plan. The need to ensure service plans provided clear direction to staff and were reflective of resident's needs and services was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/17/23 at 11:45 am. The findings were acknowledged.
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 and provided clear instruction to 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 was admitted to the facility in 06/2020 with diagnoses including dementia.Interviews with care staff and observations of Resident 1 during the survey revealed s/he was incontinent, dependent on staff for ADL care, and did not use a call light to summon assistance. Resident 1's current service plan, dated 06/09/23, failed to provide specific instruction to staff in the following areas:* Toileting; * Evacuation;* Life Enrichment;* Bathing;* Dressing/Undressing; and* Personal hygiene/oral care. The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged. 2. Resident 4 was admitted to the facility in 08/2018 with diagnoses including dementia. Interviews with care staff and observations of Resident 4 during the survey revealed s/he was incontinent and dependent on staff for ADL care. Resident 4's current service plan, dated 06/28/23, lacked specific instruction to staff in the following areas: * Toileting; * Evacuation;* Life Enrichment;* Bathing;* Dressing/Undressing; and* Personal hygiene/oral care. The need to ensure service plans provided clear direction to staff was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
3. Resident 9 was admitted to the facility in 08/2021 with diagnoses including dementia with behavioral disturbance.Observations of the resident, interviews with staff and review of the most current service plan, dated 12/21/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Diet texture and assistance with eating;* How the resident expressed pain including non-verbal expressions and location of pain;* Behavioral issues and interventions in the dining room;* Scoop mattress;* Skin monitoring including type, frequency and location of cream applied;* Two person assist with bed mobility and toileting; and* Medication management including crushing medications.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech). They acknowledged the findings.
2. Resident 10 was admitted to the facility 4/2018 with diagnoses including dementia.Observations of the resident, interviews with staff and review of the most current service plan, dated 11/15/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Cognition, including orientation, confusion and decision making;* Impaired communication, including non-verbal and staff to anticipate resident's needs;* Dressing assist, including two-person assist;* Transfer assist, including two-person assist and gait belt;* How the resident expressed pain with non-verbal expressions;* Falls, including fall interventions; and * Evacuation assistance.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech). Staff 1 acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure service plans were reflective of residents' needs and provided clear direction to staff regarding delivery of services for 3 of 3 sampled residents (#s 8, 9, and 10) whose service plans were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia.Observations of the resident, interviews with staff and review of the most current service plan, dated 11/21/23, showed the service plan was not reflective of the resident's current care needs and/or did not provide clear direction to staff in the following areas: * Two person transfers;* Two person assist with mobility, dressing, bathing and toileting; and* Diet texture including fluid consistency and assistance with eating.The need to ensure resident service plans were reflective of current care needs and provided direction to staff was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator). Staff acknowledged the findings.
SP will be reviewed with each resident surveyed and remaining residents. SP will ensure all care & health needs, diet texture, nutrition & hydration plan, preferences, outside services provided, laundry & bathing schedule are accurate and are provided in the service plan for staff direction. SP team will ensure that the plan is reflective of the care needs, provides clear direction to staff and includes the what, when, how and how often the services should be provided. This will be audited weekly by Resident Service Coordinator and Lead Med Tech as needed to ensure that Service Plan is accurate and information is being provided to care staff.Executive Director will be responsible for ensuring this is completed/monitored.

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:Resident 1, 2, 3, and 4's current service plans were reviewed during the survey. On 08/16/23 at 1:50 pm, Staff 1 (ED) confirmed the facility lacked documented evidence of a Service Planning Team to develop the individual service plan.The need to ensure service plans were developed by a Service Planning Team was discussed with Staff 1 on 08/17/23 at 12:45 pm. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment. Findings include, but are not limited to:During the survey, multiple meal observations were made of staff providing meal assistance to residents. Staff were observed wearing gloves, touching wheelchairs, cellular phones, their hair, faces and then continued to provide meal assistance without having changed their gloves.The need to ensure universal precautions for infection control were exercised, including appropriate hand hygiene, while providing meal assistance to residents, was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
1. Resident 8 was admitted to the facility in 08/2023 with diagnoses including vascular dementia.During interviews and observations from 01/02/24 through 01/03/24, Resident 8 was noted to require two person assist for mobility, toileting, dressing and required assistance with eating.During an ADL observation on 01/02/24 at 12:50 pm the following was noted:* Two staff donned gloves and assisted the resident with incontinence care which included cueing, wiping and clothing adjustment;* Two staff rolled the resident side to side to provide assistance with removal of a soiled depend;* One staff provided perineal care, then touched a clean incontinence brief, blanket and repositioned the resident using the soiled gloves;* The staff member removed the soiled gloves and did not perform hand hygiene.Maintaining effective infection prevention and control while providing incontinence care was discussed with the staff member after the ADL observation.The observation was reviewed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff 1 acknowledged the finding.2. Resident 10 was admitted to the facility in 4/2018 with a diagnoses including dementia.During interviews and observations from 01/02/24 through 01/03/24, Resident 10 was noted to require 2 person assist for mobility, toileting, dressing and required assistance with eating.During an ADL observation on 01/03/24 at 11:18 am the following was noted:* Two staff donned gloves, removed the resident's blankets, adjusted her/his clothing and transferred the resident into her/his wheelchair. * A staff member then assisted Resident 10's roommate wearing the same gloves.The observation was reviewed with Staff 1 (Executive Director) and Staff 3 (Lead MT) on 01/04/24. Staff 1 acknowledged the finding.
Based on observation and interview, it was determined the facility failed to establish and maintain infection prevention and control protocols to provide a safe and sanitary environment for 3 of 3 sampled residents (#s 8, 9, and 10) during ADL care and meal service. This is a repeat citation. Findings include, but are not limited to:

3. Resident 9 was admitted to the facility in 08/2021 with diagnoses including dementia with behavioral disturbance.During interviews and observations from 01/02/24 through 01/03/24, Resident 9 was noted to require two person assist for toileting and bed mobility. a. During an ADL observation on 01/03/24 at 1:05 pm the following was noted:* Two staff donned gloves without hand hygiene first and assisted the resident with incontinence care which included cueing, wiping and clothing adjustment;* Both staff assisted removed the soiled brief and assisted the resident onto the toilet;* One staff provided perineal care, then both staff touched a clean incontinence brief, hip protection underwear, pants, shirt, bed linens, and the bed controller while they assisted resident off the toilet and into bed, all while using the soiled gloves;* The staff members removed the soiled gloves and then performed hand hygiene after leaving the resident's room.Maintaining effective infection prevention and control while providing incontinence care was discussed with the staff members after the ADL observation.b. A med tech was observed providing wound care to Resident 9's hand at the lunch table. No hand hygiene was observed prior to or following the care. The med tech sprayed the Resident's hand, wiped the area and placed a Band Aid on the wound. No observation the table was cleaned prior to serving food. The observations were reviewed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. Staff 1 acknowledged the findings. 4. During the revisit survey, multiple meal observations on 01/02/24 through 01/04/24 were made of direct care staff providing meal service to residents. The following was noted:* Staff were observed setting tables, serving meals, and pouring beverages without wearing aprons or other barriers to prevent contamination between clothing and food;* Staff were observed entering and exiting the MCC kitchen and changing tasks without performing hand hygiene;* Meals and beverages on the food cart were not consistently covered to prevent contamination during delivery. * A staff member was observed providing one-to-one feeding assist with his mask below his nose, touching his face and hair without performing hand hygiene.* A med tech was observed in the dining room during the noon meal and provided an insulin injection to a resident. The med tech wiped the glucometer, needle capsule and her hands with the same sanitizer wipe.Maintaining effective infection prevention and control while providing meal service, food delivery and ADL care was reviewed with Staff 1 (Executive Director), Staff 3 (Lead Med Tech) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff acknowledged the findings.

Based on interview and record review, it was determined the facility failed to have a system in place for accurately tracking controlled substances administered by the facility for 2 of 2 sampled residents (#s 3 and 4) whose MARs and Controlled Substance Drug Disposition logs were reviewed for accuracy. Findings include, but are not limited to:1. Resident 3 was admitted in 07/2019 and had diagnoses which included dementia.a. Resident 3 had an order for hydrocodone-acetaminophen (narcotic analgesic) 5-325 mg, one tablet every four hours PRN for pain.Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed five occasions when staff signed on the drug disposition log that the hydrocodone was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication. b. Resident 3 had an order for morphine 7.5 mg tablet (narcotic analgesic), every eight hours PRN for pain.Resident 1's Controlled Substance Disposition Logs and MARs, reviewed from 07/01/23 to 07/31/23 , revealed three occasions when staff signed on the drug disposition log that the morphine was taken out of the locked storage to administer. However, the MAR lacked documentation that the resident received the medication.Inconsistencies between the MARs and Controlled Substance Disposition logs were reviewed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/17/23. They reviewed the documentation and acknowledged the discrepancies.
2. Resident 4 was admitted to the facility in 08/2023 and had diagnoses which included dementia.Resident 4 had a physician order for PRN morphine, 0.25 ml to be given by mouth or under the tongue every one hour as needed for pain or dyspnea.Resident 4's 07/01/23 through 08/14/23 Controlled Substance Disposition Logs and MARs were reviewed and revealed the following:Between 08/01/23 through 08/14/2023 there were two occasions staff signed the drug disposition log. However, the MAR lacked documentation the medication was administered on 08/09/23.Inconsistencies between the MAR and Controlled Substance Disposition logs were reviewed with Staff 3 (Lead MT) and the explanation offered was the MT who signed the disposition log was a new employee and she "wasn't sure why he didn't sign out on the MAR". The need to ensure the facility had a system for tracking controlled substances was discussed with Staff 1 (ED) on 08/17/23. The findings were acknowledged.

Based on interview and record review, it was determined the facility failed to ensure written, signed physician orders were documented in the resident's facility record for all medications and treatments the facility was responsible to administer for 1 of 5 sampled residents (# 7) whose orders were reviewed. Findings include, but are not limited to:Resident 7 was admitted to the facility in 02/2022 with diagnoses including Type II diabetes mellitus.Resident 7's MAR, dated 07/01/23 through 08/15/23 and prescriber orders were reviewed on 08/15/23. Resident had a physician's order for Novolog (insulin) to be administered before meals according to a sliding scale dosage. The facility did not have a signed physician's order for the resident's current sliding scale dosage.Staff 2 (RN/Resident Services Coordinator) was interviewed on 08/16/23 and was not able to locate the current signed order for the sliding scale doses. Staff 2 stated she had contacted the resident's PCP and was awaiting the order. No additional information was provided.The need to ensure the facility had signed physician's orders for all medications administered by staff was discussed with Staff 1 (ED) and Staff 2 on 08/17/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 6 of 6 sampled residents (#s 1, 2, 3, 4, 5, and 6) whose MARs were reviewed. Findings include, but are not limited to:1. Resident 1, 2, 3, 4, and 5's MARs between 07/01/23 through 08/15/23 were reviewed and the following was noted:a. Residents 3's MARs dated 08/01/23 through 08/14/23 revealed the following:Multiple incidents of medications including Eliquis (blood thinner), Gentamicin (antibiotic), and Hydroxurea (chemotherapy) with scheduled administration times left blank, failing to document administration of the medications.b. Residents 2's MARs, reviewed from 08/01/23 through 08/14/23 revealed the following:Multiple incidents of medications including buproprion (antidepressant), ezetimible (cholesterol lowering), linsinopril (blood pressure), and Insulin (blood sugar metabolism) with scheduled administration times left blank, failing to document administration of the medications.
c. Residents 1's MARs were reviewed from 07/01/23 through 08/14/23 and revealed the following:Multiple incidents of medications including, but not limited to, quetiapine (for agitation) and sertraline (for restlessness and agitation) with scheduled administration times left blank, failing to document if the medications were administered as ordered.d. Resident 4's MARs were reviewed from 07/01/23 through 08/14/23 and revealed the following: Multiple incidents of medications including, but not limited to, divalproex (for agitation), levetiracetam (for controlling seizures), and quetiapine (mood stabilization) with scheduled administration times were left blank, failing to document if the medications were administered as ordered.
e. Residents 5's MAR, dated 07/01/23 through 08/15/23, revealed the following:Multiple incidents of multiple medications, including but not limited to divalproex (for dementia), mirtazapine (for sleep) and quetiapine (for dementia), with scheduled administration times, were left blank and failed to document if the medications were administered as ordered.On 08/15/23, Staff 1 (ED) was interviewed regarding the blanks on the MAR for Resident 1, 2, 3, 4, and 5. Staff 1 reported the facility had an inadequate "WiFi" signal to capture electronic administrations in some areas of the unit. The facility did not have an effective system to audit and ensure administrations were being recorded on the electronic MAR.The need to ensure an accurate MAR was kept for all medications administered by the facility was discussed with Staff 1 (ED) on 08/15, 08/16, and 08/17/23. Staff 1 acknowledged the findings.2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder.Residents 6's MAR, dated 07/01/23 through 08/15/23, revealed the following:a. Multiple incidents of multiple medications, including but not limited to citalopram (for depressive disorder), lorazepam (for anxiety) and olmesartan (for hypertension), with scheduled administration times, were left blank and failed to document if the medications were administered as ordered; andb. Resident 6 had physician's orders including:*Lorazepam every four hours as needed for agitation/anxiety;*Haldol every six hours as needed for agitation;* Morphine every 15 minutes as needed for pain or shortness of breath; and* Hydrocodone/APAP every four hours as needed for pain.There were no resident specific parameters and instructions to staff for which medication to administer first when the resident experienced "agitation" or "pain".On 08/15/23, Staff 1 (ED) was interviewed regarding the blanks on the MAR. Staff 1 reported the facility had an inadequate "WiFi" signal to capture electronic administrations in some areas of the unit. The facility did not have an effective system to audit and ensure administrations were being recorded on the electronic MAR.The need to ensure an accurate MAR was kept for all medications administered by the facility and included resident specific parameters and instructions for PRN medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator) on 08/16/23. They acknowledged the findings.

2. Resident 10 was admitted to the facility in 04/2018 with diagnoses including dementia. Resident 10's 12/01/23 through 12/31/23 MAR and current orders were reviewed. Resident 10 had orders for:* Acetaminophen 325 mg tablet and acetaminophen 650 mg suppository were both prescribed to treat pain and fever.There were no specific parameters to guide non-licensed staff on which medication to use first when the resident experienced pain and/or fever. The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 2 of 3 sampled residents (#s 9 and 10) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 9's 12/01/23 through 12/31/23 MAR and current orders were reviewed.a. Resident 9 had the following PRN medications for pain management:* Acetaminophen 325 two tablets as needed for mild/moderate pain; * Acetaminophen 650 mg suppository as needed for mild pain; and * Morphine 20 mg/mL as needed for pain.The electronic medication record was reviewed with Staff 6 (MT) on 01/03/24. There were no specific parameters to guide non-licensed staff on which pain medication to use first. b. Resident 9 had the following PRN orders for medications for loose stools listed on the MAR:* Loperamide 2 mg "one tablet as needed for diarrhea give one tablet after each consecutive loose stool after first loose stool"; and* Loperamide 2 mg give "two tablet as needed for diarrhea give two tablets after first loose stool".The electronic medication record was reviewed with Staff 6 on 01/03/24. There were no clear parameters to guide non-licensed staff on which order to follow for bowel medications after loose stools. c. Resident 9 had a physician order to check blood pressure daily. Twelve of 31 days were left blank, failing to document resident's blood pressure.On 01/03/24 Staff 6 acknowledged that Resident 9 would not sit still and on those days staff were unable to get a blood pressure reading. She acknowledged the need to document the refusals. No further documentation was provided. The need to ensure MARs were accurate and included clear parameters to direct non-licensed staff when administering multiple PRN medications for the same condition was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/23. Staff 1 acknowledged the findings.
Paramaters were added for residents surveyed.Retraining was provided with care staff regarding refusals of medications/treatments and the importance of documentation and notification to doctor. All resident MARs were audited by Regional Director of Operations and Lead Med Tech for missing parameters. Parameters were obtained and entered for all residents. As orders arrive, they will be reviewed by Med Tech, Lead Med Tech and RSC to ensure accuracy. If paramater is missing, RSC will be notified immediately so this can be obtained and entered in MAR. MAR will be reviewed twice weekly by Lead Med Tech and/or RSC for missing parameters and to ensure all medications and treatments have been given and/or properly documented. Executive Director will review weekly with RSC to ensure these corrections are being completed/monitored.
Based on interview and record review, it was determined the facility failed to ensure MARs were accurate and included resident specific parameters and instructions for PRN medications for 3 of 4 sampled residents (#s 12, 13, and 14) whose MARs were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 13's 04/01/24 through 04/04/24 MAR was reviewed.a. Resident 13 had the following PRN medications for pain management:* Acetaminophen 325 two tablets as needed for pain; * Acetaminophen 650 mg suppository as needed for pain; and * Morphine 20 mg/mL .25 ml as needed for pain.The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no specific parameters to guide non-licensed staff on which PRN pain medication to use first. b. Resident 13's MAR listed the following medications without an indication for use:* Diltiazem CD 180 mg;* Metoprolol Tartrate 50 mg;* Quetiapine 25 mg;* Hyoscyamine sublingual 0.125 mg; and* Lorazepam 0.5 mg Tab.The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no indications for use on the MAR. c. Resident 13's MAR listed the following medications for constipation:* Senna 8.6 mg PRN "by mouth twice daily as needed for constipation;"* Polyethylene Glycol 17 gm PRN "take by mouth once daily as needed for constipation;" and* Bisacodyl 10 mg suppository "every day as needed for constipation."The electronic medication record was reviewed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They confirmed there were no specific parameters to guide non-licensed staff on which PRN bowel medication to use first.



2. Resident 12 was admitted to the facility in 04/2023 with diagnoses including dementia.The resident's 03/01/24 through 04/04/24 MAR and current physician's orders were reviewed. The following PRN medications lacked resident-specific parameters for administration:* Acetaminophen 500 mg (for pain); and * Oxycodone 5 mg (for pain). The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They acknowledged the findings.3. Resident 14 was admitted to the facility in 11/2021 with diagnoses including dementia. The resident's 04/01/24 through 04/04/24 MAR was reviewed. The following PRN medications for treating pain lacked resident-specific parameters for administration:* Acetaminophen 325 mg; and* Morphine 0.25 ml (5 mg). The following PRN medications for treating difficult breathing and/or shortness of breathing lacked resident-specific parameters for administration:* Morphine 0.25 ml (5 mg); and* Ventolin inhaler. The need to ensure the MAR included resident-specific parameters and instructions for PRN medications was discussed with Staff 1 (Executive Director), Staff 6 (Med Tech), and Staff 28 (Resident Services Coordinator) on 04/04/24. They acknowledged the findings.
Resident 13's MAR was corrected with accurate diagnosis for medications indications for use on 04/05/2024. Resident 12, 13, and 14 PRN orders were corrected with parameters by Resident Services Coordinator after order obtained from MD on 4/05/2024MAR's will be audited twice weekly for diagnosis and parameters by the Resident Services Coordinator and/or the Lead Med Tech. Any missing parameters or diagnosis will be corrected. This will be documented and kept in the RSC office and will be audited monthly by ED. New orders will be reviewed by med tech, Lead Med Tech and Resident Services Coordinator to ensure that diagnosis and paramaters are included at time of order being entered. A copy of these will be kept in RSC office for review by ED monthly. All med techs have been re-trained on identifying missing diagnosis and paramaters and on notifying management (RSC or Lead Med Tech) of any missing at time order is received. (Completed by 4/22/2024)Resident Service Coordinator is enrolled in "The Role of the nurse in CBC" on 4/23-25 and will be completing this class to increase his knowledge of nursing in RCF/ALF.

Based on interview and record review, it was determined the facility failed to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of psychotropic medications for 1 of 2 sampled residents (#6) who were receiving PRN psychotropic medications. Findings include, but are not limited to:Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia and major depressive disorder.Review of Resident 6's MAR, dated 07/01/23 through 08/14/23, and physician orders revealed the following:* Resident 6 was prescribed lorazepam 1 mg every four hours as needed for nausea/agitation/anxiety, and it was documented as administered to the resident on eight occasions between 07/22/23 and 08/11/23; and* Haldol 4 mg every six hours as needed for agitation, and it was documented as administered to the resident on seven occasions between 07/09/23 and 07/31/23.The facility lacked documented evidence non-pharmacological interventions were attempted and were ineffective prior to administration of the medications and the MAR lacked information on non-pharmacological interventions for staff to attempt.In an interview on 08/15/23, Staff 3 (Lead MT) confirmed the MAR and electronic system did not have non-pharmacological interventions listed for staff to attempt prior to administering the PRN medications. On 08/16/23, the need to ensure non-pharmacological interventions were attempted and documented to be ineffective prior to the administration of PRN psychotropic medications was discussed with Staff 1 (ED) and Staff 2 (RN/Resident Services Coordinator). They acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure an assistive device with restraining qualities was assessed by an RN, PT, or OT prior to use, and instruction provided to caregivers on precautions and correct use of the device for 2 of 2 sampled residents (#s 5 and 6) who were reviewed for devices with restraining qualities. Findings include, but are not limited to:1. Resident 5 was admitted to the facility in 11/2022 with diagnoses including Alzheimer's disease and anxiety disorder.During the survey, Resident 5 was observed while lying in bed. The bed was equipped with a half-side rail in the up position on one side of the bed. In the resident's room, a "lap buddy" type cushion was observed sitting on the wheelchair. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility and used by Resident 5 when s/he was up in the wheelchair.Resident 5's service plan, last updated 03/13/23, stated "uses lap buddy to help prevent falls". The service plan did not include any information on use of the side rail.Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 03/10/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold self up in the chair" and "releas[ing] the belt". During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) stated the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the devices.There was no assessment available for the side rail.The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings. 2. Resident 6 was admitted to the facility in 04/2023 with diagnoses including vascular dementia.Resident 6 was observed to have a "lap buddy" type cushion. Staff 3 (Lead MT) confirmed the "lap buddy" was obtained by the facility following a recommendation by PT services and used by Resident 6 when s/he was up in the wheelchair.Resident 6's service plan, last updated 07/17/23, did not include any information on use of the lap buddy.Upon request, the facility provided an "assessment of supportive devices with restraining characteristics" completed by an RN on 05/30/23, however, the assessment stated it was a review of a "lap belt". The assessment described a device used for the resident to "hold [him/her] in the chair" and "remove the belt on [his/her] own". During an interview on 08/15/23, Staff 2 (RN/Resident Services Coordinator) confirmed the document did not appear to be accurate for a "lap buddy" type device. Staff 2 confirmed the current service plan did not include instructions for caregivers on the correct use and precautions related to use of the device.The need to ensure an assessment and required documentation for devices with potentially restraining qualities was completed was discussed with Staff 1 (ED) and Staff 2 on 08/16/23. They acknowledged the findings.

Based on interview and record review, it was determined the facility failed to use an acuity-based staffing tool (ABST) that showed all residents with the 22 required care elements with staff time to complete them. Findings include, but are not limited to:ABST record system was reviewed with Staff 1 (ED) on 08/17/23 at 10:00 am. Staff 1 stated the facility was using "Point Click Care" to record the 22 required care elements and staff time to complete them. A record review of the ABST information provided by Staff 1 revealed the following: * ABST did not address all the required activities of daily living (ADLs) for each resident; and* ABST did not include the amount of staff time needed to provide care for the resident sample picked for the survey. In an interview on 08/17/23 at 1:30 pm, the need for the ABST tool to show all residents with the 22 required care elements with staff time to complete them, ensuring ABST provided data so the facility could develop a 24-hour schedule and an individualized task list was discussed with Staff 1. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to provide fire and life safety instruction to staff on alternate months from fire drills in accordance with the Oregon Fire Code (OFC), document all required components of the drills and failed to identify residents who were unwilling or failed to participate in drills. Findings include, but are not limited to:The previous six months of fire drill and fire and life safety training records were reviewed on 08/16/23 with Staff 1 (ED). The following were identified:a. Fire and life safety training for staff:* The facility lacked documented evidence of fire and life safety training for staff on alternate months.b. Fire Drills:* There was no documentation of problems encountered, comments relating to residents who resisted or failed to participate in the drills;* There was was no documented evidence the facility had identified residents who were unwilling or failed to participate in fire drills and made immediate changes to ensure evacuation standards were being met.The need to ensure fire drills were completed and all required components were documented and fire and life safety training for staff was conducted, per the rules, was reviewed with Staff 1 on 08/16/23 and 08/17/23. She acknowledged the findings.

Based on interview and record review, it was determined the facility failed to ensure residents were 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. Findings include, but are not limited to:On 08/16/23, Staff 1 (ED) was asked to explain the facility's process for providing fire safety training to residents who may be able to retain the information, upon admission and annually. Staff 1 stated there was no documentation of the facility's process and annual training was not provided to residents. No further documentation of resident training was provided.The need to have a process to identify residents who could retain the information and ensure those residents were trained in fire safety procedures upon admission and at least annually was reviewed with Staff 1 on 08/17/23. She acknowledged the findings.

Based on observation, 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 C 260, C 295, C 310, and Z 164.
Based on observation, 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. This is a repeat citation. Findings include but are not limited to:Refer to C310.

Based on observation and interview, it was determined the facility failed to ensure all interior and exterior materials and surfaces were kept clean and in good repair. Findings include, but are not limited to:The facility had recently renovated eight resident units with hard wood flooring. There were 16 rooms that had not been renovated and had carpet in the units.During a tour of the facility on 08/14/23 through 08/16/23, multiple resident rooms, including but not limited to, room #s 102, 109, 112 and 114 had large dark stains and black scuffs on the carpets. Room 105 had frayed and worn carpet, exposing the flooring beneath the carpet. The rooms in need of carpet repair were discussed with Staff 1 (ED) on 08/17/23. She acknowledged the findings.

H1517: TA was provided to ensure each individual has privacy in his/her own unit. Refer to C 200.

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 C361, C420, C422, and C513.

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 C 160, C 200, and C 295.

Based on interview and record review, it was determined the facility failed to ensure 1 of 1 newly-hired staff (#16) had the required pre-service dementia training, and 4 of 4 newly-hired staff (#s 13, 14, 15 and 16) completed all required pre-service orientation training prior to beginning their job responsibilities. Findings include, but are not limited to:On 08/15/23 at 10:30 am, Staff 13 (MT), Staff 14 (CG), Staff 15 (CG), and Staff 16's (Dietary Aide) training records were reviewed. During an interview with Staff 1 (ED), the following was identified: 1. Staff 16 hired on 06/13/23, lacked documented evidence of pre-service dementia care training for topics including:* 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; and* Information concerning specific aspects of dementia care and ensuring safety of residents with dementia including, but not limited to, how to: identify and address pain; provide food and fluid; prevent wandering and elopement; and use of a person-centered approach. 2. Staff 13 hired on 07/15/23, Staff 14 hired on 03/15/23, Staff 15 hired on 05/17/23, and Staff 16 hired on 06/13/23, lacked documented evidence of Infectious Disease Prevention training approved by the Department prior to performing job duties.The need to ensure newly-hired staff completed pre-service orientation training prior to beginning their job responsibilities was discussed on 08/16/23 with Staff 1 (ED). 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 C260, C262, C295, C302, C303, C310, C330, and C340.

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. This is a repeat citation. Findings include, but are not limited to:Refer to C 260 and C 310.
Based on 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. This is a repeat citation. Findings include, but are not limited to:Refer to C 310.

Based on interview and record review, it was determined the facility failed to ensure a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan for 2 of 3 sampled residents (#s 8 and 9) whose service plans were reviewed. Findings include, but are not limited to:Resident 8 and 9's current service plans were reviewed during survey. Each service plan lacked information and staff instructions related to the individualized nutrition and hydration status, preferences, and needs of the resident. The need to develop a daily meal program based on resident's preferences and needs that was individualized and documented in the resident's service plan was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24. Staff acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure activity evaluations addressed all required components and individualized activity plans were developed for 4 of 4 sampled residents (#s 1, 2, 3 and 4) whose activity plans were reviewed. Findings include, but are not limited to:Resident 1, 2, 3, and 4's records were reviewed, and observations were made during the survey. There was no documented evidence activity evaluations addressed the required components, and that service plans had been individualized to reflect the following:* Current abilities and skills;* Emotional/social needs and patterns;* Physical abilities and limitation; * Adaptations needed to participate;* Identification of activities for behavioral interventions; and* There was no specific activity plan which detailed what, when, how and how often staff should offer and assist each resident with individualized activities.The need to ensure activity evaluations addressed all required components and individualized activity plans were developed was discussed with Staff 1 (ED) on 08/17/23 at 12:45 pm. The findings were acknowledged.
Based on interview and record review, it was determined the facility failed to ensure all residents were evaluated for activities and/or individualized activity plans were developed for each resident based on their activity evaluation for 3 of 3 sampled residents (#s 8, 9, and 10) whose records were reviewed. This is a repeat citation. Findings include, but are not limited to:1. Resident 8's service plan offered some information about the resident's interests however, the facility had not completed an evaluation that addressed the following:* Current abilities and skills;* Physical abilities and limitations; and* Adaptations necessary for the resident to participate. The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Executive Director) and Staff 18 (LPN Resident Services Coordinator) on 01/04/24 at 11:40 am. Staff 1 acknowledged the findings.
3. Resident 10's service plan offered some information about the resident's historical interests, however, the facility had not fully evaluated the resident's current abilities and activity needs, including: * Emotional and social needs; * Current abilities and skills;* Physical abilities and limitations; and* Adaptations necessary for the resident.There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.On 01/04/24 the need to ensure the facility evaluated each resident and provided an individualized activity plan for each resident was discussed with Staff 1 (Executive Director)and Staff 3 (Lead Med Tech). Staff 1 acknowledged the findings.

2. Resident 9's service plan offered some information about the resident's interests however, the facility had not completed an evaluation that addressed the following:* Physical abilities and limitations;* Adaptations necessary for the resident to participate; and* Identification of activities for behavioral interaction. There was no specific activity plan that detailed what, when, how and how often staff should offer and assist the resident with individualized activities s/he would benefit from.The need to ensure the facility evaluated all residents for activities was discussed with Staff 1 (Executive Director) and Staff 3 (Lead Med Tech) on 01/04/24. Staff 1 acknowledged the findings.

Based on observation, interview, and record review, it was determined the facility failed to ensure the door to the secured outdoor courtyard was accessible to residents except during nighttime hours or during severe weather and to have a policy for when the doors to the outdoor areas would be locked. Findings include, but are not limited to:On 08/16/23 and 08/17/23 between 9:00 AM and 12:00 PM the weather was clear and dry with a moderate temperature. The door to a secured outdoor courtyard remained locked during that time. In an interview on 08/17/23, Staff 6 (MT) stated the door was locked because it was "too warm" for residents to go outside. Staff 6 stated she did not know the current temperature but guessed "85-90 degrees would be too warm". The policy provided by Staff 1 (ED) regarding resident access to the outdoor courtyard stated, "All care staff are to thoroughly check the courtyards multiple times a shift, at least every 1-2 hours. You are to report to the Med Tech on duty when you have checked the courtyards." Staff 1 stated the facility did not restrict resident access to the courtyard based on time of day but did restrict access based on extreme weather conditions. She acknowledged the current written policy did not clearly define these weather conditions for staff.On 08/17/23 the need to provide access to secured outdoor courtyard areas, except during nighttime hours or during severe weather was discussed with Staff 1. She acknowledged the findings.

Based on observation and interview, it was determined the facility failed to ensure residents were not locked outside of their rooms and failed to have individual identifiers to assist residents in recognizing their rooms. Findings include, but are not limited to:The MCC was toured on 08/14/23. Resident rooms 103, 111, 113, and 115 were occupied and lacked any individualized identification to assist residents in recognizing their room.During observations on 08/14/23 through 08/17/23, doors to resident rooms on the MCC unit were observed closed. Further observations revealed many of the closed doors were locked. Multiple residents were observed being unable to go into their rooms without locating staff and asking to be let in. In an interview on 08/15/23 Staff 11 (CG) stated resident's doors were locked to prevent wandering residents going into other's rooms. If residents wanted access to their rooms, they could let staff (who had keys) know and they would let them in.The need to ensure residents were not locked out of their rooms and that rooms had individualized identifiers to assist residents in recognizing their rooms was discussed on 08/17/23 with Staff 1 (ED). She acknowledged the findings.

The findings of the kitchen inspection, conducted 02/21/23, are documented in this report. The survey was conducted to determine compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules OARs 333-150-0000.
The findings of the revisit to the kitchen inspection of 02/21/23, conducted 04/24/23 are documented in this report. It was determined the facility was in substantial compliance with the OARs 411-054-0030 for Residential Care and Assisted Living Facilities and OARs 411 Division 57 for Memory Care Communities for Resident Services - Meals and Oregon Health Service Food Sanitation Rules 333-150-0000.

Based on observation and interview, it was determined the facility failed to have kitchen protocols and procedures in place according to the Food Sanitation Rules 333-150-0000. Findings include, but are not limited to: On 02/21/23 at 10:45 am, observations revealed the following: * Seven food bins in the dry storage area were not securely closed in a manner to prevent contamination and/or rodent/pest infestation; * The ceiling vent above refrigerator number 2 had a heavy build-up of dust; * The hood above the dishwashing machine had a layer of dust; * Dishwashing staff was observed to wear gloves while rinsing and racking soiled dishes, then observed to change those gloves without handwashing; and * Hair and beard restraints were not observed to be worn by two staff. The areas of concern were discussed with Staff 1 (Food Service Director), Staff 2 (ALF Administrator) and Staff 3 (Executive Director) on 02/21/23. The findings were acknowledged.

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